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TRANSFORMACIONAL
SUMÁRIO
Resumo.................................................................................................................13
Summary..........................................................................................................16
1 APRESENTAÇÃO....................................................................................18
2 INTRODUÇÃO........................................................................................21
3 JUSTIFICATIVA......................................................................................50
4 HIPÓTESE...............................................................................................51
5 OBJETIVOS.............................................................................................52
6 CONSIDERAÇÕES ÉTICAS..............................................................53
7 ARTIGOS.................................................................................................54
Artigo 1 – A pilot study of clonazepam versus
psychodynamic group therapy plus clonazepam
in
the treatment of generalized social anxiety disorder...............................55
9 CONSIDERAÇÕES FINAIS..................................................................105
LISTA DE FIGURAS
Artigo 1
Figure 1 Flowchart diagram...............................................................................62
10
Introdução
Quadro 1 Protocolo de terapia psicodinâmica em grupo para fobia
social generalizada...................................................................................34
Artigo 1
Table 1 Demographic and baseline characteristics of the
intent-to-treat population of patients receiving clonazepam
or clonazepam plus psychodynamic group therapy in
generalized social anxiety disorder..........................................................63
Artigo 3
Table 1 Repeated measures stepwise ANCOVA regarding mature,
neurotic and immature defense styles in baseline, week 6 and
week 12 comparing clonazepam or clonazepam plus
psychodynamic
group therapy in generalized social anxiety disorder..............................97
11
RESUMO
INTRODUÇÃO
A fobia social (FS), também conhecida como transtorno de ansiedade social
(TAS), é um transtorno de ansiedade crônico que causa prejuízo na qualidade de
vida. O seu subtipo generalizado (FSG) é prevalente e incapacitante, estando
associado a um pior prognóstico.
Apesar da eficácia de ambos os tratamentos psicoterápico e farmacológico,
como monoterapia, na redução dos sintomas da FSG, somente dois terços dos
pacientes que recebem tratamento são considerados respondedores, e apenas metade
desses atinge remissão dos sintomas. A maioria dos pacientes permanece sintomática
após o tratamento inicial. Até o presente momento, poucos estudos têm-se preocupado
em como aumentar a resposta ao tratamento na FSG.
OBJETIVOS
O objetivo principal do presente estudo foi comparar a eficácia da terapia
psico- dinâmica em grupo (PGT) mais clonazepam (CNZ) versus apenas CNZ como
uma estratégia de potencialização no tratamento da FSG quanto a medidas de
funcionamento global, sintomas de ansiedade social, qualidade de vida e estilos
defensivos. Um dos objetivos específicos deste estudo foi elaborar um manual de
tratamento, intitulado “Terapia psicodinâmica em grupo para fobia social
generalizada”.
MÉTODOS
Cinqüenta e oito pacientes adultos, com diagnóstico de FSG, de acordo com os
critérios do Manual Diagnóstico e Estatístico dos Transtornos Mentais (DSM-IV),
parti- ciparam de um ensaio clínico randomizado de 12 semanas: 29 pacientes foram
submeti-
14
RESULTADOS
Dados de 57 pacientes (população intent-to-treat) mostraram que o grupo PGT
mais CNZ apresentou uma melhora significativamente superior em relação ao grupo
CNZ (p=0,033) na CGI-I. Não houve diferença significativa entre os dois grupos nas
medidas de desfecho secundárias, embora, de acordo com a CGI-I igual a 1 ou 2
como critério de resposta, a diferença na taxa de resposta entre os dois grupos
aproximou-se da significância estatística (79,3% versus 53,6%, respectivamente;
p=0,052).
No que diz respeito a mudanças em estilos defensivos, em ambos os grupos
estes se modificaram ao longo das 12 semanas. No entanto, apenas no estilo defensivo
neuró- tico houve diferença significativa entre os grupos ao longo do tempo, com uma
pequena redução no grupo de tratamento combinado, e um aumento no grupointeraction
CNZ
(p
=0,045; ηp
2
=0,064). Os resultados das mudanças de estilos defensivos foram
controlados
em modelos multivariados, considerando-se sintomas de FSG e mudança sintomática
ao longo do tempo, dois confundidores conhecidos nesse tipo de estudo.
CONCLUSÃO
Este foi o primeiro estudo a comparar PGT combinada com medicação versus
apenas medicação no tratamento da FSG. Apesar de algumas limitações, nosso
estudo sugere que o acréscimo de PGT pode ser uma estratégia de potencialização
15
promissora no tratamento da FSG com clonazepam, mostrando alguns ganhos no
funcionamento global e em mudanças em estilos defensivos neuróticos no sentido de
maior adaptação, mesmo a curto prazo.
16
SUMMARY
INTRODUCTION
Social phobia (SP), also known as social anxiety disorder (SAD) is a chronic
psychiatric anxiety disorder that causes impairment in quality of life. Its generalized
subtype (GSAD) is prevalent and disabling, being associated with a worse prognosis.
Despite the efficacy of both psychotherapy and pharmacological treatments as
monotherapy in reducing symptoms of GSAD, only two thirds of patients who
receive treatment are considered responders, and only half of those achieve
remission of the symptoms. Most patients remain symptomatic after the initial
treatment. To date, a few
studies have focused on how to augment treatment response on GSAD.
OBJECTIVE
The main goal of the present study was to compare the efficacy of
psychodynamic group therapy (PGT) plus clonazepam (CNZ) versus only CNZ as an
augmentation strategy in the treatment of GSAD regarding measures of global
functioning, social anxiety symptoms, quality of life and defense styles. One of the
specific goals of this study was to elaborate a treatment manual, named
“Psychodynamic group therapy for generalizes social anxiety disorder”.
METHODS
Fifty-eight adult outpatients with a diagnosis of GSAD, according to the
Diagnostic and Statistical Manual of Mental Disorders criteria (DSM-IV),
participated in a 12- week randomized clinical trial: 29 patients underwent a
combined treatment (PGT plus CNZ) and 28 took only CNZ. Results were evaluated
under two perspectives: (I) clinical;
(II) psychodynamic.
18
The clinical evaluation of the results included the Clinical Global Impression-
Improvement (CGI-I) Scale, as the primary efficacy measure and the Liebowitz
Social Anxiety Scale (LSAS), the World Health Organization Instrument to Assess
Quality of Life-Bref (WHOQOL-Bref) Version, the Beck Depression Inventory
(BDI), as well as
the proportion of responders (defined as CGI-I ≤ 2, “much” or “very much improved”,
based only on social anxiety symptoms) and the percentage of patients in full
remission according to two different definitions: a) LSAS total score ≤ 30; b) CGI-I
score of 1 as secondary efficacy measures.
The psychodynamic evaluation of the results included the three defensive styles
– mature, neurotic and immature – as primary efficacy measures evaluated by the
Defensive Style Questionnaire (DSQ-40).
All the efficacy measures were assessed in three successive periods between
March and November 2005.
RESULTS
CGI-I data of 57 patients (intent-to-treat population) showed that the PGT plus
CNZ group presented significantly greater improvement than the CNZ group
(p=0.033). There were no significant differences between the two groups in the
secondary efficacy measures, although, according to a CGI-I of 1 or 2 as the criterion
for response, the difference in the response rate between the two groups approached
statistical significance (79.3% vs. 53.6%, respectively; p=0.052).
Regarding changes in defense styles, overall, both groups changed along the 12
weeks. Nevertheless, significant difference between groups was shown only in the in
neurotic defense style over time, with a slight reduction the combined group and an
increase in the CNZ group interaction
(p =0.045;
p η 2=0.064). The results of changes in
defense
styles were controlled in multivariable models considering SAD symptoms and its
change
over time, two well-known confounders in this type of study.
CONCLUSION
This study was the first one to compare PGT combined with medication versus
medication alone in the treatment of GSAD. Despite some limitations, our study
suggests that the addition of PGT may be a promising augmentation strategy to CNZ
showing some gains in the global functioning and changes toward greater
adaptiveness in the neurotic defense style, even in the short-term.
Future studies should investigate the effect of longer treatment protocols,
exami- ne the efficacy of the combination of PGT with different medications or with
cognitive- behavioral therapy as an augmentation strategy for the treatment of
GSAD.
19
1
APRESENTAÇÃO
REFERÊNCIAS
EIZIRIK, C.L. Psychoanalysis as a work in progress. International Journal of
Psychoanalysis, v. 87, p. 645-650, 2006.
FREUD, S. Análise de uma fobia de um menino de cinco anos (1909). In: Edição standard
brasileira das obras psicológicas completas de Sigmund Freud. Rio de Janeiro: Imago,
1972, v. 10.
KNIJNIK, D.Z. et al. Psychodynamic group treatment for generalized social phobia. Revista
Brasileira de Psiquiatria, v. 26 (suppl. 2), p. 77-81, 2004.
KNIJNIK, D.Z. et al. A pilot study of clonazepam versus psychodynamic group therapy plus
clonazepam in the treatment of generalized social anxiety disorder. European Psychiatry,
2008 (In press).
LIEBOWITZ, M.R. et al. Social phobia a review of a neglected anxiety disorder. Archives of
General Psychiatry, v. 42, p. 729-736, 1985.
ROTH, A.; FONAGY, P.. What works for whom? A critical review of psychotherapy research.
2.ed. New York: Guilford, 2005.
ZAIDER, T.I.; HEIMBERG, R.G. Non-pharmacologic treatments for social anxiety disorder.
Acta Psychiatrica Scandinava, v. 417, p. 72-84, 2003.
22
2
INTRODUÇÃO
O termo fobia deriva do grego phobos, que significa medo, terror ou pânico.
Denomina-se psiconeurose fóbica quando o sintoma se estabiliza, se reitera e abarca
progressivamente outros temores, estruturando um estado emocional característico de
alerta tenso, em uma exploração permanente de situações imaginadas pela pessoa
como potencialmente perigosas (FERRARI, 2005).
O termo fobia social (FS), também conhecido como transtorno de ansiedade
social, foi cunhado no início do século XX para descrever ansiedades de indivíduos
relacionadas à performance, isto é, ao desempenho (JANET, 1903). A FS é uma
entidade nosológica que tradicionalmente recebeu pouca atenção (LIEBOWITZ et
al., 1985), tendo sido reconhecida oficialmente como um transtorno psiquiátrico
somente após a publicação do DSM-III (APA, 1980).
DEFINIÇÃO
A FS é um transtorno de ansiedade com sintomas fisiológicos e subjetivos
proemi- nentes. A sua característica essencial é um medo acentuado e persistente de
situações sociais de interação ou de desempenho nas quais o indivíduo pode sentir
embaraço. A exposição à situação social provoca, quase invariavelmente, uma
resposta imediata de ansiedade. Adolescentes e adultos reconhecem que seu medo é
excessivo ou irracional. Mais comumente, a situação social é evitada, embora, às
vezes, seja suportada com pavor.
Nas situações sociais temidas, os indivíduos com FS experimentam
preocupações acerca de embaraço e temem ser considerados ansiosos, débeis,
“malucos” ou estúpidos. Podem ter medo de falar em público em virtude da
preocupação de que os outros perce- bam o tremor de sua voz, podem experimentar
extrema ansiedade ao conversar com outras pessoas devido ao medo de parecer que
não sabem se expressar, ou podem ainda
23
EPIDEMIOLOGIA
Em um estudo de morbidade psiquiátrica de adultos realizado em Porto Alegre,
São Paulo e Brasília, Almeida Filho et al. (1992) encontraram os transtornos ansiosos
em primeiro lugar entre os mais prevalentes diagnósticos psiquiátricos, constituindo
o principal problema de saúde mental nas regiões urbanas brasileiras. Dentre os
transtornos ansiosos, os mais freqüentes são os transtornos fóbicos.
Estudos epidemiológicos e comunitários relataram uma prevalência ao longo
da vida, variando de 3 a 13% para a FS e de 5% para a FSG (KESSLER;
McGONAGLE; ZAHO, 1994). A FSG é o terceiro transtorno psiquiátrico mais
comum, depois da fobia simples e da dependência de álcool (KESSLER; STEIN;
BERGLUND, 1998).
Na população geral, a maioria dos indivíduos com FS teme falar em público,
enquanto um pouco menos da metade teme falar com estranhos ou conhecer novas
pessoas. Outros medos relacionados ao desempenho (por exemplo: comer, beber,
escrever em público ou usar um banheiro público), parecem ser menos comuns. Em
contextos clínicos, a grande maioria das pessoas com FS teme mais de um tipo de
situação social. A FS raramente é motivo de hospitalização.
Em clínicas ambulatoriais, os índices de FS variam de 10 a 20% dos indivíduos
com transtornos de ansiedade, com ampla variação de acordo com o local
(SCHNEIER et al., 1992; KESSLER; MCGONAGLE; ZAHO, 1994). Estudos
epidemiológicos apon- tam para uma maior prevalência de FS entre mulheres,
indivíduos solteiros e com renda e nível educacionais mais baixos quando
comparados a indivíduos sem esse transtorno. No entanto, em amostras clínicas, a FS
é igualmente distribuída entre homens e mulheres. De modo geral, a FSG e as fobias
simples têm início mais precoce do que os outros transtornos de ansiedade e
apresentam-se tipicamente em uma fase intermediária da adolescência, às vezes
emergindo a partir de uma história de inibição social ou timidez na infância. A idade
média de início da FSG é em torno dos 20 anos, mas alguns indiví- duos relatam-no
em uma fase precoce da infância, e após os 25 anos de idade isso é relativamente
incomum (SCHNEIER et al., 1992; SCHNEIER, 2006). O início tanto pode seguir-
se abruptamente a uma experiência estressante ou humilhante quanto pode ser
insidioso. O curso freqüentemente é crônico e a duração é vitalícia, embora o transtor-
no possa ter sua gravidade atenuada ou remitir durante a idade adulta.
ETIOLOGIA
A FS é resultado de interações complexas entre fatores de vulnerabilidade
genéti- cos (taxa de herdabilidade estimada em 30%), biológicos, cognitivos,
comportamentais e psicodinâmicos que interagem com o ambiente familiar, o
temperamento e as experiên- cias pessoais. Diversos modelos psicológicos e
desenvolvimentais têm sido propostos na etiologia da FS (modelos baseados em
condicionamento, etiologia, personalidade,
25
COMORBIDADES
Devido à natureza do transtorno, o qual se caracteriza por medo de situações
sociais, os indivíduos com FSG geralmente são lentos na busca por tratamento e
inclusive não o fazem, a não ser que surjam outras condições como depressão,
transtorno do pânico ou alcoolismo. Logo, a presença de comorbidade é regra e não
exceção na FSG, contribuindo para a gravidade e cronicidade dos sintomas. Nesse
sentido, é fundamental que a presença de outros transtornos seja considerada na
ocasião do diagnóstico (LADER et al., 2004).
A FSG pode ser considerada um fator de risco para o desenvolvimento de
transtor- nos psiquiátricos comórbidos, principalmente depressão maior
(LIEBOWITZ et al., 2005). Por outro lado, a maioria dos indivíduos que sofre de
FSG apresenta uma ou mais condição comórbida. No eixo I, os transtornos mais
comuns são depressão maior, transtorno do pânico, agorafobia, transtorno de
ansiedade generalizada, uso de substân- cias e transtornos alimentares (SCHNEIER
et al., 1992). A presença de mais de um diagnóstico de transtorno de ansiedade na
infância pode ser considerada um fator de risco para o desenvolvimento de depressão
em pacientes adultos com FS (MANFRO et al., 2003).
De acordo com Fonagy, Roth e Higgitt (2005), a depressão comórbida tem
impacto negativo sobre a efetividade do tratamento. No eixo II (transtornos de
personalidade),
26
Ansiedade
Há pouco mais de um século, Freud cunhou o termo neurose de ansiedade e
identificou duas teorias sobre tal estado (FREUD, 1926; 1959). A primeira,
denominada teoria traumática, refere-se a uma sensação difusa de preocupação, ou de
28
medo com origem em um desejo, ou de pensamento reprimido, passível de cura com
uma interven- ção psicoterápica (“a repressão leva à ansiedade”). A segunda,
denominada teoria da
29
TRATAMENTO
Dentre os transtornos de ansiedade, a FSG é o mais crônico (GRANT et al.,
2005). Em geral, está presente por várias décadas e tem início precoce. Esse padrão
sugere que uma melhora espontânea seja rara e,quando ocorre, é gradual e verificada
em apenas metade dos portadores. A melhora dos sintomas pode acontecer no início
do tratamento, mas normalmente é contínua e lenta (SCHNEIER, 2006).
No entanto, apesar da alta prevalência e da morbidade significativa, a FSG
segue sendo um transtorno subdiagnosticado. Apenas 5% de seus portadores são
devidamente tratados, e mesmo estes são bastante resistentes ao tratamento
(KESSLER; STEIN; BERGLUND, 1998).
Na FSG, a resposta ao tratamento é definida como uma melhora clínica
significativa e estável, em que o paciente não mais apresenta todos os sintomas
iniciais, mas continua com mais de um mínimo de sintomas. A remissão ocorre
quando o paciente apresenta resolução quase completa dos sintomas de FS por um
mínimo de três meses (BALLEN- GER et al., 1998).
Nas duas últimas décadas, o entendimento acerca da natureza e do tratamento
da FSG tem evoluído muito. O crescente reconhecimento dessa condição tem sido
acompa- nhado por opções de tratamento devidamente investigadas, tanto
farmacológicas quanto psicoterápicas (RODEBAUGH; HOLAWAY; HEIMBERG,
2004; SCHNEIER, 2006),
apresentando benefícios similares a curto prazo, de acordo com ensaios controlados e
metanálises (HEIMBERG et al., 1990; GOULD et al., 1997; ZAIDER; HEIMBERG,
2003).
Apesar da eficácia de ambas modalidades terapêuticas, apenas dois terços dos
pacientes que recebem esses tratamentos são considerados respondedores, metade
deles são considerados em remissão e a maioria permanece sintomática após o
tratamento inicial ou apresenta recorrência dos sintomas a longo prazo (HEIMBERG
et al., 1998; OTTO et al., 2000; LIPSITZ; MARSHALL, 2001; DAVIDSON et al.,
2004; LIEBOWITZ et al., 2005).
34
Tratamento psicoterápico
A maior parte dos ensaios clínicos em psicoterapia para a FS utiliza abordagens
cognitivo-comportamentais, individuais ou em grupo (HEIMBERG et al., 1998;
FEDEROFF; TAYLOR, 2001; DAVIDSON et al., 2004; PICON; KNIJNIK, 2004;
ROWA; ANTONY, 2005) e terapia interpessoal (TIP) (LIPSITZ; MARSHALL, 2001;
LIPSITZ et al., 2008) como intervenção. Poucos estudos empíricos têm sido
conduzidos com outras modalidades de terapia (ALNAES, 2001; FEDEROFF;
TAYLOR, 2001; LIPSITZ; MARSHALL, 2001; RABUNG; LEIBING, 2004;
FONAGY, 2005; FONAGY; ROTH; HIGGITT, 2005; LEICHSENRING;
LEICHSENRING, 2005).
Nos últimos anos, houve vários avanços nos tratamentos psicológicos da FSG.
Mais recentemente, os pesquisadores começaram a tentar utilizar tratamentos
combina- dos para esse transtorno, bem como estratégias de tratamento inovadoras
(DAVIDSON et al., 2004; ROWA; ANTONY, 2005), já que as taxas de resposta
estão longe de ser satisfatórias (LIPSITZ; MARSHALL, 2001; ZAIDER;
HEIMBERG, 2003).
Outras modalidades de terapia, além da TCC, são necessárias para a FSG: os
tratamentos estabelecidos não beneficiam todos os pacientes e, para muitos deles,
forne- cem somente diminuição parcial dos sintomas e recorrência dos mesmos a
longo prazo (LIPSITZ; MARSHALL, 2001). Esse campo promissor precisa ser
cuidadosa e sistema- ticamente investigado e, talvez, uma forma mais apropriada de
fazê-lo seja por meio do uso de métodos qualitativos, ao lado da metodologia
quantitativa amplamente utilizada na literatura.
A eficácia dos tratamentos psicológicos para FSG foi abordada em algumas
revi- sões (CHAMBLESS et al., 1998; DERUBEIS; CRITS-CHRISTOPH, 1998;
CHAMBLESS; OTTENDICK, 2001; ROTH; FONAGY, 2006). Até o presente mo-
mento, poucos trabalhos empíricos têm sido realizados utilizando abordagens
psicoterápicas que não sejam cognitivo-comportamentais para o tratamento de FSG,
tais como psicoterapia psicodinâmica (LIPSITZ; MARSHALL, 2001; ALNAES,
2001; LEICHSENRING, 2004; 2005; KNIJNIK et al., 2004; LEAHY et al., 2005).
As abordagens psicanalíticas tendem a ser aplicadas mais amplamente no
diagnós- tico generalizado de neuroses de caráter, sem especificações ou modificações
de técnicas para tratamento de determinados transtornos (ZIMMERMAN, 1998;
1999; BUSCH; MILDROD; SINGER, 1999). Em uma revisão recente sobre
terapias psicológicas e
35
seus desfechos, restrita à língua inglesa, não são mencionados estudos com terapia
psicodinâmica, nem individuais nem em grupo, para a FSG (FONAGY, 2003; 2005).
Nesse sentido, Knijnik et al. (2004) realizaram um ensaio clínico randomizado,
comparando terapia psicodinâmica de grupo (PGT), através de um manual de
tratamento específico para FSG, com um grupo placebo com credibilidade controlada
em 30 pacien- tes por 12 semanas. Os autores concluem que a PGT foi superior ao
grupo placebo com credibilidade no tratamento da FSG na amostra estudada quanto a
medidas de sintomas. Manuais de tratamento psicodinâmico para transtornos de
ansiedade foram desen- volvidos para transtorno de ansiedade generalizada (CRITS-
CHRISTOPH et al., 1995; LEICHSENRING et al., 2005) e transtorno de pânico
(MILROD et al., 1997; 2001; 2007). Recentemente, Leichsenring et al. (2007)
desenvolveram um manual de terapia de apoio-expressiva individual para FS e
Knijnik et al. (2004; In press) propuseram um
manual de terapia psicodinâmica em grupo para FSG.
• Orientação conceitual
A orientação conceitual de PGT é psicanalítica, baseada na hipótese de que
confli- tos internos recorrentes e inconscientes estejam ligados aos sintomas de FSG.
O objetivo primário da PGT é valorizar o insight dos pacientes a respeito de conflitos
recorrentes. A técnica psicoterápica utilizada na PGT foi adaptada da psicoterapia
psicanalítica bre- ve proposta de Malan (1976; 1979), usando-se algumas de suas
sugestões e a experiên- cia clínica prévia dos autores (EIZIRIK et al., 1998; 2006;
2008; LEMGRUBER, 2008). Em contribuições anteriores, Eizirik et al. (1991)
descreveram a relevância de ligar sintomas a conflitos específicos e a importância da
transferência e da contratransferência.
36
• Fases da PGT
Com base na revisão da bibliografia publicada e em nossa experiência clínica
anterior (EIZIRIK; KAPCZINSKI, 1991; KNIJNIK et al., 2004), consideramos que
as seguintes fases, com suas respectivas características, ajudam a realizar a PGT de
maneira consistente com a sua conceitualização (Quadro 1).
Quadro 1
Protocolo de terapia psicodinâmica em grupo para fobia social generalizada
Sessão Objetivos Procedimentos
• Indicações
A PGT é indicada para pacientes com FSG com motivação explícita para
mudar o seu padrão de relacionamento e não apenas obter alívio dos sintomas. Os
pacientes precisam ser capazes de tolerar os níveis moderados de ansiedade e
frustração que podem surgir durante a psicoterapia, estabelecer contato com
participantes em grupo e ter tido pelo menos um relacionamento interpessoal
significativo durante a infância (BUSCH; MILDROD; SINGER, 1999; KNIJNIK et
al., 2004; YALOM; LESZCZ, 2005).
• Vantagens
A PGT parece ser um tratamento viável para indivíduos que sofrem de FSG. O
fato de ser realizada em um ambiente de grupo é particularmente relevante, já que o
próprio grupo proporciona uma fonte de melhoria dos sintomas de ansiedade. Uma
vantagem possível da PGT é o fato de que a experiência de grupo e o insight parcial
sobre os conflitos inconscientes podem ter um efeito sinérgico sobre a melhora
clínica. A psicoterapia de grupo é um tratamento eficiente e econômico para uma
grande variedade de transtornos mentais e usa um setting sob condições específicas
para alcançar metas terapêuticas. É de baixo custo em termos econômicos, mas
propicia grande riqueza de desfechos potenciais (KNAUSS, 2005). A terapia de grupo,
conforme descrita, permite a combinação de uma abordagem psicoterápica - feita pelo
terapeuta – e de uma abor- dagem com maior apoio – feita pelos membros do
grupo. Portanto, permite que os pacientes elaborem seus conflitos e que o terapeuta
adquira maior familiaridade com as
relações de objeto.
Tratamento farmacológico
A FSG responde com freqüência ao tratamento farmacológico, com um início
de ação mais imediato e efeitos mais robustos a curto prazo do que a TCC
(HEIMBERG et al., 1998). Apesar do uso maciço de psicofármacos na FSG, as taxas
de resposta estão entre 50-70% ao término de 2-3 meses de tratamento, e mesmo nos
pacientes ditos responsivos algum sintoma residual acaba permanecendo, enquanto
apenas 20-30% dos pacientes experimenta remissão significativa (DAVIDSON, 2003;
SEEDAT; STEIN, 2004).
Atualmente, de acordo com ensaios clínicos randomizados e metanálises
(GOULD et al., 1997; FEDEROFF; TAYLOR, 2001; BLANCO; ANTIA;
LIEBOWITZ, 2003;
STEIN et al., 2004), as evidências indicam que muitos fármacos são úteis no
tratamento da FSG e superiores ao placebo, tais como: inibidores seletivos de
recaptação da sero- tonina (ISRS), agentes noradrenérgicos (IRNS), inibidores da
monoaminoxidase (IMAOs) e benzodiazepínicos. Outras categorias de fármacos com
provável eficácia incluem os outros agentes gabaérgicos (por exemplo, gabapentina e
novos derivados).
39
Benzodiazepínicos
A FS pode ser concebida em termos biológicos como a ativação da “reação de
defesa” (GRAEFF, 2003), expressão cunhada em 1943 por Hess e Brueger. Uma
outra opção terapêutica na FS são os benzodiazepínicos, que sabidamente podem
atenuar essa reação de defesa.
Dentre os benzodiazepínicos, o clonazepam tem sido o mais extensamente
estuda- do. O seu uso no tratamento agudo está associado a um melhor prognóstico em
ambas as situações: quando é usado como monoterapia e quando é empregado em
associações (DAVIDSON; TUPLER; POTSS, 1994). Ao considerarmos os ensaios
clínicos controla- dos conjuntamente, os benzodiazepínicos demonstraram ser mais
eficazes do que o placebo, desempenhando um papel relevante no manejo dos
sintomas. Podem ser consi- derados fármacos importantes tanto como primeira
escolha em indivíduos que não tole- ram ou não estão em condições de receber ISRS
ou IRSN quanto como segunda escolha. Ainda podem ser utilizados junto aos
antidepressivos para respondedores parciais.
Em uma pesquisa realizada em 1983, no Encontro Anual do Colégio
Americano de Cardiologia, Gossard, Dennis e Debusk (1984) descobriram que alguns
apresentadores mencionavam fazer uso do benzodiazepínico diazepam para alívio de
sua ansiedade de performance. Os primeiros relatos de resposta aos
benzodiazepínicos foram publica- dos em 1988. O alprazolam foi estudado em dois
ensaios abertos. Um foi um estudo de caso com quatro pacientes que apresentaram
melhora dos sintomas da FS em doses de 3-8 mg/dia (LYDIARD et al., 1988). Outro
grupo examinou 14 pacientes com FS pelo DSM-III. Embora todos os pacientes
tenham apresentado melhora dos sintomas da FS, de acordo com a escala de
impressão clínica global (CGI), em doses variando entre 1-7 mg/dia, uma semana
após a descontinuação houve piora (REICH; YATES, 1988). O último estudo que
avaliou o alprazolam como uma possível alternativa de trata- mento para a FS foi um
ensaio clínico randomizado de 12 semanas com 65 pacientes com FS (26 com o
subtipo generalizado) que receberam tratamento com (1) TCC, ou
(2) fenelzina e auto-exposição, ou (3) alprazolam e auto-exposição, ou (4) placebo e
auto-exposição. A dose média de alprazolam foi de 4,2 mg/dia. Não houve diferenças
estatisticamente significativas entre os quatro grupos de tratamento quanto à resposta
ou
40
• Clonazepam
Desde meados da década de 1980, diversos estudos estabeleceram a eficácia
an- tipânico do clonazepam, bem como o seu uso no tratamento de outros distúrbios,
como o transtorno afetivo bipolar e a FS (ROSENBAUM, 2004). O clonazepam, um
benzo- diazepínico de alta potência, tem sido extensivamente estudado para o
tratamento da FS (ROBINSON; HOOD, 2007). Em um ensaio aberto, Versiani,
Nardi e Mundim (1989) trataram 40 pacientes com FS (de ambos os subtipos) com
uma dose media de clonazepam de 3,8 mg/dia com melhora significativa na LSAS
(81,6 para 31,6) e na CGI (5,0 para 2,1) na oitava semana do estudo.
Em 1990, uma série de ensaios clínicos abertos foi realizada: o clonazepam foi
efetivo e bem-tolerado em uma dose média de 3 mg/dia em cinco indivíduos, de
acordo com a escala de impresão clínica global (CGI), na oitava semana de
tratamento. Um dos cinco pacientes ficou assintomático por 12 meses após a
descontinuação do clona- zepam. Os autores também concluíram que, comparado a
outros agentes usados para a FS, o clonazepam é mais fácil de ser usado, devido à
sua meia-vida mais longa (ONTIVEROS; FONTAINE, 1990).
Em um estudo-piloto com clonazepam em 23 pacientes com FS pelo DSM-III-
R, houve melhora significativa no grupo tratamento, com uma dose média de
clonazepam de 2,75 mg/dia – variação de 1-6 mg/dia – em relação ao grupo controle
sem tratamento, nas medidas dos sintomas de FS, na oitava semana do estudo
(MUNJACK et al., 1990). Em geral, a sedação inicial que ocorreu nos pacientes em
uso de clonazepam desapareceu espontaneamente ou com a redução da dose. Embora
o estudo não fosse duplo-cego nem controlado por placebo, tivesse curta duração e
contasse com uma amostra pequena, os dados preliminares foram suficientes para
41
encorajar estudos adicionais.
42
(0,5 versus 3,0), fizeram menos visitas médicas nos últimos 6 meses (1,1 versus 2,3)
e apresentaram menores escores na Liebowitz Disability Scale (7,2 versus 29,1). Os
autores sugerem que tais achados podem ser devidos a uma melhora global de saúde
mental e física resultante da participação em um protocolo de tratamento.
Mais recentemente, Versiani et al. (1997) observaram que 86,8% de 40
pacientes tratados em estudos abertos com clonazepam (dose média diária de 4,8 mg)
melhoraram ao longo de 16 semanas de tratamento. Apenas dois casos saíram do
estudo por conta do efeito adverso de disfunção sexual.
Um ensaio clínico de curto prazo estudou a combinação de paroxetina com clo-
nazepam versus paroxetina com placebo (SEEDAT; STEIN, 2004), paroxetina (20-
40 mg) com clonazepam (0,5 mg duas vezes ao dia por 1 semana; 1,0 mg duas vezes
ao dia por 9 semanas) ou placebo, seguidos de descontinuação gradual por 2 semanas.
A paro- xetina (máximo 50 mg) foi então continuada por mais 8 semanas. Embora o
estudo tenha iniciado com 28 pacientes, houve 9 perdas, com apenas 50% de poder
para detector diferença entre os grupos. O grupo clonazepam apresentou maiores
reduções em escalas específicas de FS, dentre elas a LSAS, do baseline para as
semanas 10 e 20. Os efeitos adversos foram similares entre os grupos. Os efeitos
colaterais que foram no mínimo 10% superiores do que com o placebo incluíram
náusea, ansiedade, aumento de sudorese, inquietude, diminuição de libido, ejaculação
retardada e anorgasmia.
Otto et al. (2000) realizaram um estudo randomizado para examinar a eficácia
do clonazepam em comparação à terapia cognitivo-comportamental (TCC) em grupo
no tratamento da FS e para determinar os possíveis fatores indicativos de resposta ao
trata- mento. Os pacientes com FS (N=45) foram randomicamente distribuídos para o
tratamen- to. A intensidade dos sintomas, de acordo com a avaliação do clínico e do
próprio pacien- te, foi avaliada no baseline e após 4, 8 e 12 semanas. Os resultados
mostraram que os pacientes de ambas as modalidades terapêuticas melhoraram
significativamente, sendo a melhora do grupo em uso de clonazepam superior de
acordo com algumas das escalas da semana 12. A intensidade dos sintomas foi
negativamente associada ao sucesso do trata- mento em ambos os grupos, mas nenhum
outro fator foi capaz de predizer a evolução. Os pacientes que haviam sido
distribuídos para o grupo em uso de clonazepam ou para o grupo de TCC
apresentaram probabilidades iguais de responder ao tratamento agudo.
Em um estudo de retirada de clonazepam com pacientes que apresentaram
resposta favorável a doses médias de 2,0 mg de clonazepam em um ensaio aberto de
6 meses, de acordo com a CGI, 36 pacientes foram randomicamente alocados entre
continuar o clonazepam e descontinuar com substituição por placebo por 5 meses.
Nenhum paciente em uso de clonazepam apresentou recaída, mas 21,1% do grupo
placebo apresentaram uma piora dos sintomas. O baixo índice de recaída no grupo
placebo sugere um benefício contínuo após a retirada do clonazepam (ensaio aberto),
principalmente porque o estudo excluiu TCC concomitante. Os autores concluem que
o tratamento com clonazepam a longo prazo é seguro e eficaz na FS (CONNOR et
al., 1998). No entanto, de acordo
44
Tratamento combinado
Estudos mais atuais mencionam a importância de associações de fármacos e
psi- coterapia como possíveis alternativas na melhora de pacientes com FS. No
tratamento farmacológico, os benzodiazepínicos são comumente prescritos como
agentes adjuntos ou alternativos devido à sua rápida ação ansiolítica (SEEDAT;
STEIN, 2004).
Quanto ao tratamento combinado, em um ensaio clínico recente, a D-
cycloserina (HOFMANN et al., 2006) mostrou-se superior ao placebo em sua
combinação com terapia de exposição.
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3
JUSTIFICATIVA
4
HIPÓTESE
5
OBJETIVOS
OBJETIVO GERAL
OBJETIVOS ESPECÍFICOS
6
CONSIDERAÇÕES ÉTICAS
7
ARTIGOS
60
a
Post Graduate Program in Medical Sciences: Psychiatry. School of Medicine, Universidade
Federal do Rio Grande do Sul and Anxiety Disorders Program, Hospital de Clínicas de Porto
Alegre.
b
Columbia University and New York State Psychiatric Institute, NY, United States of America
Abstract
Background – Both Psychodynamic Group Therapy (PGT) and clonazepam are used
as treatment strategies in reducing symptoms of generalized social anxiety disorder
(GSAD). However, many individuals remain symptomatic after treatment with PGT or
clonazepam.
INTRODUCTION
Treatment strategies for Social Anxiety Disorder (SAD) have focused on
psychotherapy and pharmacotherapy [49,51]. Controlled trials and meta-analyses
suggest similar benefits from both psychological, mainly cognitive-behavioral
therapy (CBT), and pharmacological [25,27,60] in the short-term treatment of SAD.
Monoamine oxidase inhibitors, selective serotonin reuptake inhibitors,
noradrenergic agents and the high-potency benzodiazepines, clonazepam and
bromazepam have demonstrated efficacy for SAD [7,48].
To date, most clinical trials of psychotherapy have used CBT [16,17,28,50] and
interpersonal therapy (IPT) [40,41] as the experimental intervention. Very little
empirical work has been conducted using other psychotherapy approaches
[1,20,36,37,41]. More systematic research using therapy modalities other than CBT is
needed in GSAD because many patients achieve only partial decrease in symptoms or
experience recurrence of symptoms in long-term follow-up [16,41].
Most of what is known about psychoanalytic treatment for GSAD comes from
case reports or uncontrolled studies [21,31,35,55]. Although psychodynamic
psychotherapy has been shown in other disorders [8,34,43,45,59], there is only one
published study suggesting its efficacy in GSAD [33]. In a recent study thirty
patients were randomized to PGT or to a control group for 12 weeks in order to
evaluate the efficacy of PGT. The control group consisted of an educational supportive
psychotherapy group previously used by Heimberg et al. [27] to examine the efficacy
of group CBT. At the end of the study, patients randomized to PGT were rated as
more improved than controls in one of the efficacy measures, with an effect size for
the interaction term in the ANOVA of 0.1 (Partial Eta Squared; p=0.036), considered
a medium effect size, suggesting that PGT may be a possible alternative to CBT or
IPT for patients with GSAD [33].
Despite the efficacy of both psychotherapy and medication, only two thirds of
patients who receive these treatments are considered responders, only half of those
are considered remitters and most patients remain symptomatic after the initial
treatment [28,38,46]. However, in contrast with the vast literature in the treatment of
major depressive disorder (MDD), to date, only a few studies have focused on how to
augment treatment response on GSAD. The present study was designed to compare
the efficacy of PGT plus clonazepam versus clonazepam in the treatment of GSAD.
We chose clonazepam based on the promising results of prior studies
[14,29,46,52,57], as well as relapse prevention effects with long-term clonazepam
treatment in SAD [9].
62
METHOD
Study design
This was a randomized, 12-week study of PGT plus clonazepam versus
clonazepam in 58 adult outpatients of the Anxiety Program of Hospital de Clínicas de
Porto Alegre (HCPA), Brazil, who met the DSM-IV [2] criteria for GSAD as
determined by the Mini International Neuropsychiatric Interview (M.I.N.I.) –
Portuguese Version 5.0 [3]. The study was approved by the Institutional Review
Board (IRB) of HCPA. All subjects provided written informed consent prior to their
enrollment in the study.
Prestudy procedures
The trial was conducted between March 2005 and November 2005. Participants
were recruited from clinical referrals and media advertisements. Patients referred to
the study were assessed by two psychiatrists with expertise in SAD to determine
eligibility and willingness to participate. The assessment included a psychiatric
history and the MINI [3]. Eligible subjects were randomly assigned to receive PGT
plus clonazepam or clonazepam alone using a list of random numbers provided by a
statistician not otherwise involved in the clinical trial. Randomization was stratified
by symptoms severity using a cut off score of 82 in the LSAS total score [39], as
suggested by prior studies [44]. After randomization, patients were scheduled for the
pretreatment (i.e., baseline) assessment.
Patient sample
Inclusion criteria. Outpatients, 18-65 years old, who met DSM-IV criteria for
primary diagnosis of GSAD for at least 2 years, and had a baseline LSAS of at least
55, with fear and/or avoidance in =4 social situations (at least 2 involving
interpersonal interactions).
Exclusion criteria. A history of failure to respond to 2 mg of clonazepam taken
for at least 12 weeks, hypersensitivity to benzodiazepines, prior or current
psychotherapy for SAD (regardless of response). Current comorbid anxiety disorders
whose symptoms were more severe than those of SAD, a depressive episode
(BDI=30), or suicide risk, in the previous 6 month, bipolar disorder or substance use
disorder (except nicotine dependence). Mental retardation or any neurological
disease, use of psychotropic medications (including hypnotics) in the 4 weeks prior
to the study, and women breastfeeding, pregnant or unwilling or unable to take
adequate contraceptive precautions.
63
Treatments
Clonazepam treatment: Pharmacologic treatment consisted of individual 20-
minute visits in weeks 1, 2, 4, 6, 8 and 10. Patient adherence to the medication
regimen was measured by pill count.
No systematic psychotherapic interventions (cognitive, behavioral or
interpersonal) were delivered during the visits. Clonazepam regimen was started at an
initial dose of
0.5 mg taken twice a day in the first week. The dose could be increased to up 1.0 mg
taken twice a day in weeks 2-12 to maximize response. Dose reduction was allowed
if necessary to improve tolerability (0.5 mg/day and 1 mg/day were considered
minimum doses in week 1 and in weeks 2-12 respectively). At the end of the
treatment period clonazepam was gradually discontinued using a fixed-dose taper of
0.25 mg/day every 2 weeks. Therefore, 16 weeks were required to taper off patients
receiving the maximum dose of 2.0 mg/day. Safety assessments were based on reports
of adverse events (possible adverse effects were monitored).
PGT and clonazepam treatment: The PGT intervention consisted of 12 weekly
90-minute group sessions using a treatment manual (available from Dr. Knijnik upon
request) developed for a previous randomized trial of PGT versus educational
supportive psychotherapy group [33]. The number of patients varied from 8 to10
patients (mean 9) per group. Three groups, led by the first author (D.Z.K.), were
conducted to achieve the sample size needed for the study.
The psychotherapeutic technique used in PGT was derived from Malan´s [42]
focused, short-term psychoanalytic psychotherapy, based on the hypothesis that
recurrent and unconscious internal conflicts are connected to the symptoms of SAD.
The conceptual justification for the use of a group psychodynamic treatment
for GSAD is the idea that the symptoms and behaviors of individuals reflect the
unconscious processes [23] that defend against their repressed wishes, fantasies, and
impulses [53]. As with other psychological symptoms, from a psychodynamic point
of view, SAD is a symptom of a conflict. Individuals with SAD are conflicted about
the wish to exhibit their sexual or aggressive urges. Social anxiety can be both an
expression of the conflict and a punishment for the patient’s wishes. Avoidance of
social situations contributes to avoidance of the conscious experience of these wishes.
Clinical work suggests that certain internal object relationships are
characteristic of individuals with SAD. Specifically, these patients have internalized
representations of parents, caretakers, or siblings, who shame, criticize, ridicule,
humiliate, abandon, and embarrass them. These perceptions are established early in
life and later repeatedly projected onto persons in the environment who are then
avoided, for fear of criticism and rejection. It is a tendency of punishing themselves
for their angry feelings and fantasies towards parents or other meaningful people in
their lives [24,61].
Its two phases help deliver PGT in a manner consistent with its conceptualization:
Phase I includes two individual evaluation interviews with the group therapist to obtain
64
Efficacy measures
The Clinical Global Impression – Improvement subscale (CGI-I) [26] is a 7-
point clinician-rated scale to assess treatment response, ranging from 1 (“very much
improved”) to 7 (“very much worse”). It was a structured interview to assess
exclusively social anxiety symptoms. The CGI-I was completed by the blind
independent evaluator (C.U.M.) previously trained in rating of the CGI scales in SAD
patients. Before each assessment patients were reminded not to discuss their
treatment in order to maintain its blind condition.
The LSAS [39] is a 24-item scale designed to assess both social interaction and
performance-related anxiety in both severity of fear and anxiety and frequency of
avoidance. A recent study [9] comparing the LSAS clinician-rated version (LSAS-CR)
to its self-rated version (LSAS-SR) found that LSAS-SR is comparable to LSAS-CR
and it is reliable. In the present study the LSAS-SR was administered with
instructions read to the patients prior to the administration of the scale [4,10,22].
65
Efficacy evaluation
The primary efficacy measure was mean change from baseline of CGI-I total
score, which was assessed at weeks 2, 4, 6, 8, 10 and 12.
The CGI was chosen as primary outcome measure to be consistent with prior
studies that had investigated the efficacy of clonazepam in the treatment of SAD
[9,12- 15,46]. The continuous measure was chosen instead of the cut-offs because it
increases power to detect differences between groups.
Secondary efficacy measures included the proportion of responders (defined as
CGI-I = 2, “much” or “very much improved”, based only on social anxiety
symptoms) and the percentage of patients in full remission according to two different
definitions:
a) LSAS total score = 30; b) CGI-I score of 1 [49]. Additionally, mean change from
baseline to endpoint of LSAS-SR total score and BDI were assessed at weeks 1, 6
and 12 and WHOQOL-Bref was assessed at weeks 1 and 12.
Treatment adherence
Fidelity to the manual was monitored through detailed written transcription of
all sessions with the therapist (D.Z.K.) receiving weekly supervision on a once a
week basis by the last author (C.L.E.), a training and supervising analyst of the
International Psychoanalytic Association, with over 5 years of experience providing
PGT. Adherence to the manual was measured by two independent raters, in order to
evaluate if the therapist followed properly the manual within its three phases.
Additionally to the adherence to the manual, the degree of the psychoanalytical
concept was also evaluated. To access the adherence to psychoanalytical concept of
PGT developed by D.Z.K, two independent raters evaluated the sessions through the
written transcriptions and provided blind ratings using a structured instrument called
Instrument for Evaluation of Psychoanalytical Psychotherapy Sessions – Group
version (IEPPS-G) [11] found to be reliable between raters and capable of
distinguishing PGT from another form of therapy.
The IEPPS-G was developed in our center to evaluate the psychoanalytical
basis of therapeutic sessions. It is a 6-item instrument 5-point Likert scale, ranging
from 0 to 30, with higher scores representing a higher psychoanalytical construct. The
instrument
66
Statistical analysis
Kolmogorov-Smirnov test and Levene’s test were used to evaluate normality of
distribution and homogeneity of variances, respectively, prior to any statistical
testing. Independent samples t-tests were used to examine differences in
demographic and baseline characteristics between groups. Mann-Whitney Test was
used to examine variables that did not follow a normal distribution. Categorical data
were compared using Chi-square test and Fisher´s Exact test. Linear Mixed Models
[56] were used to examine changes over time in the two treatment groups in CGI-I,
LSAS-SR, WHOQOL- Bref, BDI and to evaluate the role of possible confounding
factors.
The kappa coefficient was used to evaluate the agreement between the two
independent evaluators regarding PGT treatment adherence to IEPPS-G.
Results are considered significant at the á=0.05 level (two-tailed). All analyses
were conducted using the SPSS 14.
RESULTS
A diagram of the patient flow in the study is presented in Figure 1. No
statistically significant differences between groups were detected with regard to
demographic characteristics or mean baseline rating scale scores (Table 1). There
were no significant differences in the proportion of patients who completed the study
in each treatment group: 28 (96.6%) in the PGT and clonazepam group and 24
(82.1%) in the clonazepam group (Fisher’s Exact p-value=0.102). Neither MDD nor
Panic Disorder as comorbidities was associated with treatment outcome (data not
shown).
Regarding treatment adherence, both independent raters agreed that the
therapist followed properly the manual within its three distinct phases. They also
rated IEPPS-G higher than 17 (mean 25.6; SD=2.7; min=18 max=29) showing a high
psychoanalytical concept present across the sessions.
67
Table 1
Demographic and baseline characteristics of the intent-to-treat population of patients
receiving clonazepam or clonazepam plus psychodynamic group therapy in
generalized social anxiety disorder
Psychiatric Comorbidity*
Any other psychiatric disorder 23 (82.1) 22 (75.9) .747a
Major depressive disorder 12 (42.9) 6 (20.7) .092a
Panic disorder 11 (39.3) 5 (17.2) .082a
Agoraphobia 18 (64.3) 13 (44.8) .186a
Generalized anxiety disorder 13 (46.4) 14 (48.3) >.999a
WHOQOL-Bref Domains
Physical 56.4±14.6 59.8±16.4 tdf=55=-0.83 .410b
Psychological 46.0±13.1 52.7±16.2 tdf=55=-1.73 .090b
Social Relationship 47.0±20.9 47.4±19.6 tdf=55=-0.07 .942b
Environmental 47.6±14.1 54.7±16.3 tdf=55=-1.76 .085b
Note: Values represent count (percent), mean ± SD or median (inter-quartile range). Statistic: aFisher’s Exact test,
b
Independent samples Student’s t-test, cPearson Chi-square test, dMann-Whitney test, estandardized score for the
Mann-Whitney test. Abbreviations: CNZ = Clonazepam, PGT = Psychodynamic Group Therapy, LSAS =
Liebowitz Social Anxiety Scale (self-report version), CGI-S = Clinical Global Impression Scale – Severity of
Illness, BDI = Beck Depression Inventory, WHOQOL-Bref = World Health Organization Instrument to Assess
Quality of Life (bref version), df = degrees of freedom. * Reported only for disorders present in at least 10% of
each group.
69
Efficacy outcomes
Consistent with our hypotheses, we found that the PGT plus clonazepam group
showed significantly greater improvement than the clonazepam group (F=2.47, df=5,
p=0.033) in the CGI-I (Table 2). Also consistent with our hypotheses, there were no
differences in the BDI between the groups. In contrast, we failed to find significant
differences in the LSAS-SR and in the domains of WHOQOL-Bref (Table 3).
Using a CGI-I of 1 or 2 as the criterion for response, the difference in the
response rate of PGT plus clonazepam versus clonazepam approached significance
(79.3% vs. 53.6%, respectively; Fisher’s Exact p-value=0.052). However, there were
no significant difference between remission rate in PGT plus clonazepam and
clonazepam treatment groups based on the LSAS total scores (10.3% vs. 3.6%;
Fisher’s Exact p-value=.611) or on the CGI-I score of 1 (31% vs. 25%; p=.770).
Drug dosage
Mean dosage over the study period was calculated by dividing the total number
of milligrams taken during the study by the number of treatment days. The mean
dose for the PGT plus clonazepam group was 1.29±0.35 mg/d. (t=1.849, df=55,
p=0.07). The mean dose for the clonazepam group was 1.48±0.41 mg/d. The mean
dose for the PGT plus clonazepam group at week-12 was 1.51±0.525 mg/d. The
mean dose for the clonazepam group at week-12 was 1.67±0.53 mg/d (t=1.1, df=55,
p=0.3).
Safety
There was no unexpected or serious adverse events. Adverse events were
reported by a similar proportion of individuals in both treatment groups: 28 (96.6%)
in the PGT plus clonazepam treatment group and 23 (82.1%) in the clonazepam
treatment group (Fisher’s Exact p=.102). Only one adverse event, decreased libido,
was less evident in the combined treatment group (p=0.012). Most of the adverse
events were mild in severity.
DISCUSSION
This study is the first to compare combined medication and PGT versus
medication alone in the treatment of GSAD. Our findings suggest that PGT plus
clonazepam may be a promising strategy for the treatment of GSAD, regarding gains
in the global functioning as measured by the CGI-I. However there were no
differences in the other outcome measures evaluated.
Table 2
Linear mixed models of CGI-I comparing clonazepam versus clonazepam plus psychodynamic group therapy in generalized social anxiety
disorder
CNZ 3.2±1.1 2.9±1.1 2.5±1.2 2.4±1.1 2.3±1.1 2.5±1.3 0.58 <.001 .389 .033
Note: Values represented mean ± SD. Abbreviations: CNZ = Clonazepam. PGT = Psychodynamic Group Therapy. Statistic: a Week-2 to Week12; b Linear Mixed Models
65
Table 3
Linear mixed models of LSAS, BDI and WHOQOL-Bref comparing clonazepam or clonazepam plus psychodynamic group therapy in
generalized social anxiety disorder
Baseline Week 6 Week 12
2
CNZ CNZ+PGT CNZ CNZ+PGT CNZ CNZ+PGT p-values (ηp )
Symptomatic scales
LSAS 91.1±22.6 92±24.7 76.9±24.3 78.1±26.1 74.3±25.9 71.4±27.4 <.001 .965 .657
BDI 15.4±7.1 13.7±9.1 11.2±7.1 10±7.4 12.2±8.6 9.4±8.9 <.001 .298 .710
WHOQOL-Bref
Quality of life domains
Physical 56.4±14.6 59.8±16.4 60.8±14.9 62.7±16.2 .074 .462 .713
Psychological 46.0±13.1 52.7±16.2 51.0±15.7 57.5±17.2 .010 .081 .932
Social Relationship 47.0±20.9 47.4±19.6 49.1±22.5 52.9±21.5 .097 .687 .454
Environmental 47.6±14.1 54.7±16.3 47.9±13.8 56.3±16.6 .513 .047 .632
General Quality of Life 50.9±18.6 55.6±21.8 57.1±17.1 68.1±16.2 <.001 .083 .148
Note: Values represent mean ± SD. Abbreviations: CNZ = Clonazepam., PGT = Psychodynamic Group Therapy, LSAS = Liebowitz Social Anxiety Scale (self-report version), BDI = Beck
Depression Inventory, WHOQOL-Bref = World Health Organization Instrument to Assess Quality of Life (bref version). Statistics: a Linear Mixed Models
66
67
Our results are the first to provide some preliminary support for an
augmentation strategy to medication treatment for GSAD. To date, only one other
published study has examined this question. Davidson et al. [16] conducted a
randomized trial (N=295) to examine improvement in response rates with the
addition of fluoxetine to CBT and found that, addition of fluoxetine resulted in less
than 3% incremental improvement of the combined treatment group over the CBT
group, suggesting that combined treatment did not yield any further advantage over
CBT alone.
Our study adds to a growing literature suggesting possible benefit of combined
treatment over monotherapy for anxiety disorders, for example, in a treatment trial
for panic disorder comparing CBT, imipramine and their combination, Barlow et al.
[5] found combined treatment superior to either monotherapy. Similar findings have
been suggested by some authors for the treatment of chronic MDD [30,32]. On the
other hand, a recent study [19] found no benefit of adding clomipramine to CBT in the
treatment of obsessive-compulsive disorder, reinforcing the hypothesis of combined
treatments not being systematically superior to monotherapy.
On other measures in our study, both groups similarly improved in specific
symptomatic domains as measured by the LSAS, in the psychological domain and in
the general measure of quality of life as measured by the WHOQOL-Bref. However,
we did not detect statistically significant differences between the treatment groups.
Failure to detect differences in general quality of life appears to be related to limited
power, although no differences were detected between groups in any domain of
WHOQOL-Bref, even in the social relationship domain. The reasons for the
discrepancy between clinician-rated scales (CGI) and self-rated scales (LSAS-SR)
are less clear and may represent differences in response perception between
clinicians and patients, a finding previously documented in depression [30,32,54] or
it may be accounted for the fact that the addition of PGT to clonazepam was more
effective in decreasing the global functioning but not the SAD symptoms considered
alone. Furthermore, although the LSAS-SR has good psychometric properties to
assess severity of SAD cross-sectionally, it may be less sensitive to change than other
outcome measures [10]. Future augmentation studies should compare the sensitivity to
change of the LSAS-CR versus the LSAS-SR. The mean maximum dose of
clonazepam in our study was 1.35 mg/day in both groups, lower than the mean
maximum dose of clonazepam in two prior studies. However, there were no
differences in medication dose between groups. This dose (0.5-2.0 mg/day) was
chosen to prevent adverse effects (e.g. daytime sleepiness, cognitive disturbances) that
are more common with higher doses and may interfere with patient functioning
[14,58]. Consistent with this intent, clonazepam was well tolerated. We are aware of
the fact that by limiting clonazepam dose we provided only an attenuated form of
clonazepam treatment. Consistent with this, response to clonazepam was smaller
than that reported in prior studies using higher doses.
68
Our study has some limitations. First, our study had a relatively small sample
size, limiting our power to detect significant results in certain measures. Second, this
sample was composed of treatment-seeking patients who had GSAD with some
restrictions at the enrollment phase (e.g., no severe depressive symptoms) and
therefore our results may not be generalized to all patients with GSAD. Third, our
study lasted only 12 weeks, a relatively short treatment period for a condition as
chronic as GSAD. It is possible that longer periods of psychotherapy may be needed
to obtain the full benefit of PGT for GSAD [47]. Also, due to its pilot nature, the study
did not include a CBT arm, precluding a direct comparison of this treatment. There is
a potential bias from the potentially single-blind assessment. Furthermore, it is
possible that the relatively superiority of PGT could be due to nonspecific effects
such as increased attention, or a natural process of exposure inherent to any group
therapy.
Despite these limitations, our study suggests that the addition of PGT may be a
promising augmentation strategy to clonazepam with some gains in the global
functioning of patients with GSAD.
Future studies should investigate the effect of longer treatment periods,
examine the efficacy of combining PGT with different medications, and compare
PGT versus CBT as a strategy for the treatment of GSAD.
CONCLUSION
This study provides empirical information of a relatively understudied and
novel approach that has possible benefits regarding the global functioning of those
suffering from GSAD.
ACKNOWLEDGMENTS
This research was partially supported by the FIPE-HCPA, CNPq and by NIH
grants DA00482, DA020783 and DA019606 (Dr. Blanco).
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73
Daniela Z. Knijnik, M.D.a, Carlos Blanco, M.D. Ph.D.b, Carolina Moraes, M.D.c,
Giovanni A. Salum Jr.d, Cláudio L. Eizirik, M.D., Ph.D.e
a
Psychiatrist. Member of the Post Graduate Program in Medical Sciences: Psychiatry. School of
Medicine, Universidade Federal do Rio Grande do Sul and member of the Anxiety Disorders
Program, Hospital de Clínicas de Porto Alegre.
b
Psychiatrist at Columbia University and New York State Psychiatric Institute, NY, United States
of America.
c
Psychiatrist of the Anxiety Disorders Program, Hospital de Clínicas de Porto Alegre, Department
of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
d
Medical School of the Federal University of Rio Grande do Sul, Hospital de Clínicas de Porto
Alegre, Porto Alegre, Brazil.
e
Psychoanalyst and President of the International Psychoanalytic Association. Member of the
Socie- dade Psicanalítica de Porto Alegre, SPPA, Brasil. Professor at the Postgraduate Program
in Medical Science, Psychiatry, Federal University of Rio Grande do Sul, Hospital de Clínicas de
Porto Alegre, Porto Alegre, Brazil.
INTRODUCTION
Social anxiety disorder (SAD), also known as social phobia, is a chronic
psychiatric disorder of adolescent onset with lifetime consequences and significant
economic costs, often leading to long-term disability in the social, work, and family
domains, and decreased quality of life (Grant et al., 2005; Schneier, 2006). In its
generalized form (GSAD) it may seem to be a type of extreme shyness or variant of
avoidant personality disorder and enduring and resistant to change (Robinson &
Hood, 2007).
Treatment strategies for GSAD have focused on psychotherapy, mainly
Cognitive Behavioral Therapy (CBT) (either individual or group) and
pharmacotherapy (Rowa & Antony, 2005) with similar benefits (Zaider & Heimberg,
2003) in the short-term. In recent years there have been several advances in the
psychological treatments of GSAD as researchers have begun to look at combined
treatments for this disorder as well as new and innovative treatment strategies (Rowa
& Antony, 2005), given that response rates are far from satisfactory (Zaider &
Heimberg, 2003; Davidson et al., 2004; Lipsitz & Marshall, 2001).
The efficacy of psychological treatments for GSAD has been addressed in
several reviews (Chambless et al., 1998; Chambless & Ollendick, 2001; DeRubeis &
Crits- Christoph, 1998; Roth & Fonagy, 2006). To date, very little empirical work
has been conducted using non-CBT approaches, such as psychodynamic
psychotherapy (Lipsitz & Marshall, 2001; Leahy et al., 2005; Alnaes, 2001;
Leichsenring, 2004; 2005a). Psychoanalytic approaches have tended to be more
broadly applied to generalized diagnosis of character neuroses, without specifications
or modifications of treatment techniques for particular disorders (Busch, Mildrod, &
Singer, 1999).
While treatment manuals have been developed for psychodynamically oriented
individual therapy for Generalized Anxiety Disorder (Crits-Cristoph et al., 1995;
Leichsenring et al., 2005b), Panic Disorder (Milrod et., 1997) and SAD (Leichsenring
et al., 2007), to date, no manual for a psychodynamic group treatment of GSAD
exists. We address this need by describing a manual for a short-term psychodynamic
group therapy (PGT). Its conceptual orientation is psychoanalytic, adapted from
Malan´s focused, short-term psychotherapy in which the author tries to understand
each case focusing the treatment in the main conflict identified connecting past
and present in the formulation of a specific focus, and the previous clinical
experience of the authors. This therapy, PGT, was used in two clinical trials
conducted by our group, one evaluating the efficacy of PGT in patients with GSAD
(Knijnik et al., 2004) and the other comparing a combined treatment, PGT plus
clonazepam, with clonazepam alone
as an augmentation strategy for GSAD patients (Knijnik et al., In press).
75
Clinical example
In this clinical example it is shown that within the concept of psychic
determinism, there is room for choice. In the third psychodynamic group session, P.,
a 20-year-old male, diagnosed with GSAD, a mechanic who worked at a garage,
whose symptoms were preoccupation with the thought that his supervisor was critical
of him and a gene- ral inhibition when thinking of his supervisor.
In the course of PGT, it emerged that P. had the unconscious fantasy that his
father was never as close to him as he felt the father was to his siblings. Through the
treatment, he was gradually able to remember the lack of dialogue between him and
his father. He always felt frustrated, believing that he was not the person his father
wanted him to be, and that when he went out with his friends, his father did not like
it. The therapist helped P. recognize that feelings of inferiority were triggered in him
every time the patient believed his supervisor was staring at him for evaluation
purposes. The therapist also helped P. become aware of the conection between
GSAD symptoms and his feeling of being judged, in the past by his father, projected
into his supervisor in the present. Acceptance by the supervisor represented a feeling
of compensation of his fantasy of being rejected by his father.
His difficulty in social interaction was related to his difficulty in
communicating with his father, who used to avoid him at home. His symptoms of
GSAD improved during the 12-week group therapy, as he was able to bring this
conflict into consciousness. He was able to work much better than before when
watched by his supervisor, without a constant feeling of being judged. He also felt
more like a real adult, rather than like a
76
young boy conflicted between a desire to be loved by his father and the painful
feeling of being rejected by him something that was described by Luborsky´s (1984)
as a core conflictual theme. He experienced this rejection as a failure to meet his
father’s expectations. Unable to solve this conflict, P. unconsciously repeated it in all
his other relationships, especially feeling rejected by figures of authority which was
manifested through inhibition. The fact of exposing his conflict in the group setting
might have provided a positive impact on his improvement.
Transference
Group therapy allows the formation of multiple transferences: the patient´s
transference to the therapist and to other group members and transference to the
group as a whole. In the group setting qualities of the object relations of each patient
and feelings associated with them will be attributed to the therapist as well as to the
group members. In this sense, transference represents therapeutic material which
needs to be understood (Gabbard, 1994a). The therapist must be particularly alert to
each patient´s feelings of shame. The patients may anticipate that the therapist will be
as critical and rejecting of him as he expects others will be. This can be used as an
opportunity to explore an early transference reaction from each patient to the therapist
and other group members and to examine each patient´s reaction that might be
experienced toward the therapist and other group members (Gabbard, 1994d).
In psychodynamic therapy sibling rivalry and transference wish to be the
therapist’s favourite patient are common. However, in group therapy this issue may
appear more prominently (Yalom, 2005).
Clinical example
In the fifth psychodynamic group session, the therapist was delayed for 15
minutes on her way to the hospital. She called the secretary and asked her to tell the
patients she would be late. The same patient of the first clinical example, P., whose
treatment focus was a lack of attention from his father since his youth, decided not to
wait. He did not attend the sixth session. He came the session after and said nothing
about that episode but mentioned having had a hard time regarding somatic
symptoms, like blushing, tachycardia and mind going blank with his colleagues at
work. It was understood that P. was repeating in his current group experience a
pattern of relationship that began with the infantile experience with his father. During
that meeting the therapist was able to show P. that some aspects of his relationship
with his father were unconsciously ascribed to his current relationship with her and
also with the group. Specifically, P. was reexperiencing the feeling of lack of
attention from his father in the therapist’s delay, feeling that the therapist was
neglecting him, a manifestation of transference.
77
Compromise formation
Conflict produces signal anxiety, which results in defense, which leads to a
compromise between the id and the ego. The symptom, in the following clinical
example, reflects the core psychodynamic concept known as compromise formation;
i.e., it contains both the direct expression of an underlying wish and a defense against
that wish (Brenner, 1982). As with other psychological symptoms, from a
psychodynamic point of view, GSAD is a symptom of a conflict and also represents a
compromise formation. Individuals with GSAD are conflicted about the wish to
exhibit their sexual or aggressive urges, thus GSAD, according to Leahy et al. (2005)
can be both an expression of the conflict and a punishment for wishes underlying it
as well as wishes of dependency needs or needs for relationship as in the case of the
20 year old man described above. Avoidance of social situations contributes to
avoidance of the conscious experience of these wishes. Similarly, anxiety and
avoidance punish the individual for angry feelings and fantasies. Efforts at
idealization of self or others attempt to ward off painful feelings of low self-esteem
but then add to the potential for disappointment.
Clinical example
S. is a 37 year old woman. When she was younger she felt very embarrassed
when friends came visit her parents. She always experienced her parents as very cold
and distant, her father as a neglectful figure in her life and her mother as always
critical and furious at her.
On one occasion, when she was 2 years old, and she and her familiy had
recently moved from another town, her mother wanted to introduce her to a group of
friends. The patient had just learnt how to walk alone, and when the mother opened
the door and her friends started coming into their living room and greeting S., the
patient seemed frightened to see so many people. She suddenly stopped walking and
went back to crawling for the next 6-12 months.
In the twelfth week of group therapy, S. could clearly understand the
relationship between the conflict (a desire of being admired when walking versus the
fear of losing her mother’s care) and the symptom (severe anxiety). She became even
more convinced that social situations such as establishing eye contact, starting a
conversation, introducing herself in a group setting would trigger her anxiety
symptoms. During the 12 weeks the therapist pointed out the use of regression and
displacement as defense mechanisms, meaning that aggression at her mother and
father was being projected in various social situations, especially those with stronger
interactive components.
78
Clinical example
M., a 23-year old man, in medical school, developed GSAD symptoms at the
age of 8 of severe blushing, tachycardia, mind going blank and voice trembling when
interacting with his supervisor and colleagues at rounds or when speaking in public,
which caused major social impairment in medical school. M. stated that he grew up
with his older brother and younger sister, since his parents worked all day. He felt a
lot of pressure from his older brother, who liked to be in a dominant position in their
relationship and was verbally and physically aggressive towards him. He was
supposed to obey and he felt very small when his brother became aggressive.
79
of him, triggering social anxiety. Additionally, patients experience guilt about their
anger at others for being critical and rejecting, and for their own aggressive yet denied
wishes for attention. Social anxiety can serve as a punishment for this guilt (Leahy et
al., 2005).
In addition to conflicts with the experience of anger, socially anxious patients
struggle with intense feelings of inadequacy.
When these forbidden aggressive or sexual thoughts that might lead to
retaliatory punishment threaten to emerge from the unconscious, signal anxiety is
activated, which leads to the deployment of three defense mechanisms –
displacement, projection, and avoidance (Nemiah, 1981). These defenses eliminate the
anxiety by once again repressing the forbidden wish, but the anxiety is controlled at
the cost of originating GSAD.
Clinical example
An example of this diffuse sense of worry originating in a repressed wish that
could be cured with psychotherapeutic intervention is provided by a clinical example
of a 33-year old patient with the diagnosis of GSAD. J. was the eldest brother of 5
children raised by his mother. His father neglected them, drank heavily and often
engaged in physical fights with their mother at home. From the beginning of
treatment, he related his childhood history to his current anxiety symptoms. They
were all abandoned by his father on a Christmas Eve. Because of his father’s absence
from home, the patient alternated between intense anger and rage, and a feeling of
being responsible for what his father had done.
The same clinical example can help us provide a brief illustration regarding
focus formulation which means determining the symptoms, defenses and conflicts in
order to achieve psychodynamic comprehension. Throughout therapy, it was clear
that his relationship with his mother was intense and it possibly made him become a
workaholic at a young age, in an attempt to control his anger toward his father figure
and to substitute him. His symptoms of social anxiety began by the age of 10,
immediately after they were abandoned by his father. In one of the sessions, J. told
the group that even though his father was a good swimmer he had always been afraid
of swimming in the sea. During a summer vacation, the father took both his sister
and him and went all the way into the sea, against their will. He remembered feeling
very frightened by the big waves and suddenly the waters were so deep that his father
had a hard time protecting them. Again, his anger at his father appeared in a session.
The unconscious conflict was identified and the focus of his therapy was established:
a desire to take his father’s place versus a fear of being drowned by his father.
81
Group format
The group meets once a week for 12 weeks. Each session lasts 90 minutes. The
number of patients varies from 8 to 10 per group. Patients of both genders are
included in the group. The group is closed. Although we have not examined this
issue systematically, based on clinical experience, we believe that group composition
powerfully influences the quality of interaction among group members and thus
treatment outcome. PGT groups are heterogeneous in terms of age, gender and
conflicts of the members to encourage a rich group interaction, but homogeneous
regarding diagnosis of GSAD, the presence of a focal issue to discuss and the level of
frustration its members can cope with. Members isolated from the rest of the group
are likely to find the experience threatening.
Conceptual orientation
The conceptual orientation of PGT is psychoanalytic, based on the hypothesis
that recurrent and unconscious internal conflicts are connected to the symptoms of
82
GSAD. The primary object of PGT is to enhance the patients´ insight about recurrent
conflicts. The psychotherapeutic technique applied in PGT was adapted from Malan
´s (1976) focused, short-term psychoanalytic therapy, using some suggestions from
Malan and the previous clinical experience of the authors (Eizirik, Wilhelms, Padilha,
& Gauer, 1998). Malan’s main contributions include the relevance of motivation,
focalization and the use of selective attention to a main area of conflict of the life of
the patient. Eizirik & Kapczinski (1991) in previous contributions described the
relevance of connecting symptoms with specific conflicts and the importance of
transference and counter-transference. The group setting works as a scenario for
enactment of each patient specific conflict the group´s dynamic and the therapist aims
to show this connection. PGT uses a more individual-centered approach (Wolf, 1983)
where the process is conceptualized as similar to individual psychotherapy and
psychoanalysis in a group setting. The group process itself is relatively less important
than interpretation of the individual´s difficulties in dealing with the other group
members and with the therapist. Of course there are common group experiences
shared by everyone that deserves interpretation (Gabbard, 1994d).
In short, our view is that therapy change occurs largely thru insight based on
the therapist’s interpretations but also takes advantage of the emotional experience
offered by the group setting.
Clinical Vignette
B., a 30 year old woman, developed a severe fear of interacting with people at
work. Whenever a colleague at work came to her and said “good morning” she
experienced intense anxiety and blushing. When forced to confront any social
interacton situation, her face would become completely red and she would stumble
over her words and also would not be able to complete a sentence.
In a group session, another group member did not recall her name and wanted
to mention something about her. When he asked the therapist, and not her, what her
name was, her face became red, she did not say a word and started to hide her face
and cry. The whole group remained in silence for several minutes. The therapist said
to the group:
T: What is each one of you feeling in this situation?
B.: I feel completely ridiculous, because it is not normal to get this red even
here in the group where we are all victims of the same problem. I find it impossible
to communicate with people, but that is ok, someday I will get over it... he simply
asked me what my name is and I froze.
T: What did you feel when R. mentioned something about
you? B.: I don’t know.
T: Try to think for a while, what comes to your mind?
83
B.: (Crying) that when I was a little girl and was responsible for taking care of
my younger brother, during the day, while my parents went to work I felt bad about
it. I never understood what exactly my mother expected from me...and every night
when she came home she would open the door and call me, and the first question was
always regarding my brother, not me.
T: So you had to take care of him when you were also a little girl. How old
were you then?
B.: 7, 8, 9...and even now that both of us are grown up and live here in Porto
Alegre, only the two of us, I feel the same about him.
T: How do you feel about him?
B.: Responsible but unable to take care of him.
T: So you had to take care of him while your parents were out working. I
wonder if when you were mentioned in the group you felt, as in the past, responsible
for answering without being able to do so.
B.: Maybe yes...participating here in the group and mainly having their
attention called to me is the same as feeling responsible for my brother and having to
answer my mother about my performance during the day.
The vignette above is the sixth session of our first clinical trial (Knijnik et al.,
2004). It exemplifies the basic understanding of GSAD and its application to a patient
´s personal history and it demonstrates the relation of the patient’s internalized
relationship to the mother (feeling dismissed or playing ‘second fiddle’ to the
younger sibling) and her blushing in the group.
The therapist uses mainly individual extra-transferencial interpretations and
also takes advantage of the group dynamics to formulate transference interpretations
in order to increase partial insights. It can be seen that B., in a sense, is enacting her
conflicts in the group setting, and the therapist tries to show her, as well as the group
as a whole, how each new situation might represent the relief of a specific situation
that is possibly linked to the current symptom. B., in her communications to the
group, at the end of the session, seems to understand this kind of connection.
TREATMENT ADHERENCE
For the assessment of fidelity to the manual we suggest monitoring group
sessions through transcriptions. Adherence to the manual and to psychoanalytical
concept can
85
Also, special attention has to be given to the amount of time offered to the
examination of each patient’s conflict in the group sessions. Complex symptom-
conflict correlations are more difficult to interpret in the short-term since it might
take longer to be understood.
CONCLUSION
PGT appears to be a viable treatment for individuals who experience GSAD in
its generalized subtype. The fact that it is performed in a group setting is especially
relevant since the group itself provides a source of improvement of anxiety
symptoms. One possible advantage of PGT is the fact that the group experience and
the partial insight on the unconscious conflicts might have a synergistic effect on the
clinical improvement. According to the clinical examples presented in this article, it
was possible to see that patients under PGT apparently face their conflicts more
directly, thus having a shared opportunity to face the external and hidden contents at
the same time.
In order for a psychodynamically oriented therapist to use this manual three
main aspects must be considered: some knowledge of the phenomenology,
psychodynamics and treatment of GSAD and of psychodynamic group therapy which
is conducted in the framework of Wolf, i.e. individual work utilizing group activities,
where the process is conceptualized as similar to individual psychotherapy and
psychoanalysis in a group setting. Also, we recommend that the therapist conduct at
least 3 training 12 week PGT sessions.
PGT constitutes the first manualized approach to the psychodynamic group
treatment of GSAD. The results of two trials (Knijnik et al., 2004; 2008, in press),
although preliminary, suggest that PGT is acceptable to patients and may be useful
both as monotherapy and as an augmentation strategy to the pharmacological
treatment of GSAD. Although further research is needed to confirm the efficacy of
this novel approach to group treatment of GSAD, in conjunction with the work of
Busch et al. (1999), Crits- Christoph et al. (1995), Milrod et al. (2007), Leichsenring
(2007), our work suggests that manualized psychodynamic therapies may constitute a
promising alternative to the treatment of anxiety disorders.
Group therapy is an efficient and economic treatment for a great variety of
mental disorders and uses a natural setting under specific conditions to achieve
therapeutic goals. It is low cost, not just in economic terms, but also in the wealth of
potential outcomes (Knauss, 2005). Group therapy, as presented above, allows a
combination of a psychodynamic approach – done by the therapist – and a more
supportive approach – done by group members. Therefore, the patient might be able
to work through both conflicts and ego deficits, and the therapist might be able to
gain greater familiarity with the patient´s internal object relations in a much shorter
time.
87
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a
Post Graduate Program in Medical Sciences: Psychiatry. School of Medicine, Universidade
Federal do Rio Grande do Sul and Anxiety Disorders Program, Hospital de Clínicas de Porto
Alegre.
Ramiro Barcellos 2350, room 400N, CEP 90035-003, Porto Alegre, RS, Brazil
b
Columbia University and New York State Psychiatric Institute, NY, United States of America
1051 Riverside Drive, Unit 69, New York, NY 10032
Abstract: The aim of this study was to examine changes in defense styles when
comparing clonazepam to psychodynamic group therapy plus clonazepam in
generalized social anxiety disorder (GSAD) during 12 weeks. Fifty-seven patients that
met DSM-IV criteria for GSAD participated in the study. SAD symptoms were
evaluated with the Liebowitz Social Anxiety Scale, while and defense styles were
assessed with the Defense Style Questionnaire. In general, all defense styles changed
over time for both groups, especially mature defense style, that increased
independently of the treatment allocation group. Additionally, we found a time
treatment interaction in the regression analyses of changes in neurotic defense style
over time after controlling for potential confounders. Whereas in the combined group
there was a slight reduction in neurotic defenses, in the CNZ
group there was an increase over time (p
interaction =0.045;
p η 2=0.064). The same
phenomena
seems to occur with immature style, however without statistical significance. The
authors conclude that it is possible for neurotic defense style to change toward
greater adaptiveness with the addition of PGT to clonazepam in GSAD, even in 12
weeks, highlighting an additional gain provided by PGT, despite the small effect size
of this advantage.
* Preparado para enviar para submissão para o Journal of Nervous and Mental Disease.
92
INTRODUCTION
Controlled studies have demonstrated the efficacy of manualized
psychodynamic therapy for the treatment of several psychiatric disorders (Fairburn et
al., 1986; Brom et al.,1989; Garner et al., 1993; Gowers et al., 1994; Shapiro et al.,
1994; Fonagy et al., 2005; Leichsenring et al., 2004; 2007; Milrod et al., 2007),
including generalized social anxiety disorder (GSAD) (Knijnik et al., 2004; Knijnik
et al. [In press]). Nevertheless, most studies use only standard clinical outcomes,
such as symptoms severity, when evaluating the results of psychodynamic oriented
therapy. An important question seldom examined is whether clinical outcomes are the
only gains provided by psychotherapy approaches (Leichsenring, 2005; 2006). The
evaluation of other outcomes, especially those hypothesized by psychodynamic
theory to change such as defense mechanisms, should be systematically addressed in
those studies. Changes in defense mechanisms could represent potential gains in the
level of functioning and quality of interpersonal relations.
In fact, the defense mechanisms concept is largely used to evaluate functioning,
under an ego psychology perspective. Defense mechanisms are automatic
psychological processes that protect the individual against the awareness of internal
and external dangers and stressors (APA, 1994). Therefore they could represent how
individuals react to conflict (Andrews et al. 1989; Blaya et al., 2003). In order to
present defense mechanisms in a hierarchical way, Vaillant (1971; 1976) classified
them into three levels of maturity derived from psychodynamic theory and based on
empirical research (Vaillant, 1986). These levels are called defense styles (mature,
neurotic and immature). Since dynamic psychotherapy specifically addresses
defenses and conflicts, Bond and Perry (2004) have advocated the examination of the
empirical evidence that treatment can lead to more adaptive defense styles.
Some studies have found changes in defense styles over time with long-term
psychodynamic approaches (Bond et al. 2004). However, other studies in panic
disorder patients have also examined this question with other treatment modalities
and noted that some types of defense styles can also change with pharmacological
approach (Kipper et al., 2005) or non-psychodynamic therapies such as CBT (Heldt
et al., 2007). These findings raise the question of whether defense styles can change
with non psychodynamic approaches and whether they are biased by confounding
factors as symptoms severity and symptomatic change. Additionally, to the authors’
knowledge, no prior study has evaluated changes in defense styles in the short-term
with a psychodynamic approach. The goal of this study was to assess changes in
defense styles, in a trial comparing Clonazepam alone versus Clonazepam plus
Psychodynamic Group Therapy for GSAD.
We hypothesized that addition of PGT would lead to a greater increase in mature
defense and a decrease in the use of immature and neurotic defenses.
93
METHODS
Participants
Fifty-eight outpatients from the Unit of the Anxiety Program of Hospital de
Clí- nicas de Porto Alegre (HCPA), Brazil were included in randomized clinical trial
to receive Psychodynamic Group Therapy and Clonazepam (PGT+CNZ) or
Clonazepam alone (CNZ). The study was approved by the Institutional Review Board
(IRB) of HCPA and all subjects provided written informed consent prior to the
enrolment in the study. The standard efficacy outcome measures of this trial are
available elsewhere (Knijnik et al., [In press]).
Patients had to meet DSM-IV (APA, 1994) criteria for the diagnosis of SAD,
ge- neralized subtype (fear or avoidance of most interaction and performance social
situations), as determined by the Mini International Neuropsychiatric Interview
(M.I.N.I.) – Portuguese Version 5.0 (Amorim, 2000), a standardized and structured
diagnostic interview.
Instruments
Both clinician rated-assessment Clinical Global Impression Scale (CGI; Guy,
1976) for severity (CGI-S) and improvement (CGI-I) were completed by an
individual blind to treatment condition. Patient-rated measure included the Liebowitz
Social Anxiety Scale Self-Report Version (LSAS-SR; Liebowitz, 1987). All
interviews were conducted by trained psychiatrists.
The defense style was assessed with the Defense Style Questionnaire-40 (DSQ-
40), a self-administered scale developed by Bond et al. (1983) and Andrews et al.
(1993), without relying exclusively on clinical opinion, at baseline, week 6 and week
12. The DSQ-40 relies on conscious derivates of defense mechanisms. The DSQ-40
evaluates 20 defenses, which are divided into three factor groups: mature, neurotic
and immature. Five defenses are related to the mature factor (sublimation, humor,
anticipation, rationalization and suppression); four to the neurotic factor (undoing,
pseudo altruism, idealization and reaction formation) and eleven to the immature
factor (projection, passive-aggression, acting out, isolation, devaluation, “autistic
fantasy”, denial, displacement, dissociation, splitting and somatization). The
individual defense scores are calculated by the average of the two items for each
determined defense mechanism, and the factor scores are calculated by the average of
the scores of the defenses that belong to each factor. Each item is evaluated on a scale
from 1 to 9, where “1” indicates “completely disagree” and “9” indicates “fully
agree”. Higher scores indicate greater use of mechanisms comprised in each
category. The DSQ-40 has been translated and validated into Portuguese version
(Blaya et al., 2004), with internal consistency of each defense factor, discriminant
validity, and test-retest reliability (Blaya et al., 2007).
94
Treatments
Clonazepam. Pharmacological treatment consisted of individual 20-minute
visits in weeks 1, 2, 4, 6, 8 and 10. Patient adherence to the medication regimen was
measured by pill count. No systematic psychotherapeutic interventions (cognitive,
behavioral or interpersonal) were delivered during the visits. Clonazepam regimen
was started at an initial dose of 0.5 mg taken twice a day in the first week and
increased to up 1.0 mg taken twice a day in weeks 2-12 to maximize response, based
on clinical response and tolerability.
PGT and clonazepam. The PGT intervention consisted of 12 weekly 90-minute
group sessions using a treatment manual (available from Dr. Knijnik upon request)
developed for a previous randomized trial of PGT (Knijnik et al., 2004). The
psychotherapeutic technique used in PGT was derived from Malan´s (1976) focused,
short-term psychoanalytic psychotherapy, based on the hypothesis that recurrent and
unconscious internal conflicts are connected to the symptoms of SAD. The
conceptual justification for the use of a group psychodynamic treatment for SAD is
that the symptoms and behaviors of individuals reflect the unconscious processes
(Freud, 1953) that defend against their repressed wishes, fantasies, and impulses
(Shapiro, 1992).
As with other psychological symptoms, from a psychodynamic point of view,
SAD is a symptom of a conflict. PGT is divided into two phases: Phase I includes
two individual evaluation interviews with the group therapist to obtain a psychiatric
and developmental history and to conceptualize each patient’s focus. Phase II
comprises 12 group sessions, divided into sessions 1-3 (address group formation,
ensuring patients’ agreement to focus exclusively on the treatment of GSAD and
focus formulation), sessions 4-10 (the possible connection between symptoms and
conflicts is investigated and interpreted as appropriate) and session 11-12 (discuss
issues related to treatment termination). Patients in the combined treatment received
PGT and clonazepam simultaneously, according to the procedures described above.
Treatment adherence
Fidelity to the manual was monitored through detailed written transcription of
all sessions with the therapist (D.Z.K.) receiving supervision once a week by the last
author (C.L.E.), a training and supervising analyst of the International Psychoanalytic
Association, with over 5 years of experience providing PGT. Adherence to the manual
was measured by two independent raters, in order to evaluate if the therapist
followed properly the manual within its three phases.
Additionally, adherence to psychoanalytic concept was ensured by the
Instrument for Evaluation of Psychoanalytical Psychotherapy Sessions (IEPPS;
Hauck et al.,[in press]) – a validated structured instrument adapted for group sessions
that reliably distinguishes PGT from other therapy modalities, such as cognitive
behavior therapy.
95
The instrument assesses the following items (on scale of 0-30): neutrality,
characteristics of the intervention, use of interpretation, use of psychoanalytic theory
to understand the material and therapeutic aspects specifically related to the group
setting. Scores above 17 indicate adherence to psychoanalytic concept, distinguishing
psychoanalytic sessions from another form of therapy (Anexos F e G).
Statistical analysis
Data are presented as mean ± standard deviation and count (%). For the
baseline comparison between the two groups Fisher’s exact test, independent samples
Student’s t-test, Pearson chi-square test and Mann-Whitney test were used. Due to the
small sample size of the study, we used a stepwise approach within the Repeated
Measures Analysis of Covariance (ANCOVA) in order to control for confounding
factors and to evaluate the effect of modeling interaction terms.
Firstly, all variables that differed between the two groups with a p-value of less
than .20 were evaluated as covariates. Secondly, the following variables were
evaluated as theoretical predictors of defense styles change over time: social anxiety
symptoms at baseline (LSAS-SR), symptomatic change assessed by LSAS-SR over
the clinical trial (endpoint LSAS-SR minus baseline LSAS-SR), and each baseline
defense style. Thirdly, the multivariate models were constructed as follows: each
variable that was in agreement with steps one or two was retained in the final model
that evaluated the role of adding PGT to CNZ in each defense style change over time
for mature, neurotic and immature independently.
Data analysis was performed per protocol. Partial eta squared (η p2) was used to
estimate effect size in the final multivariable models. The kappa coefficient was used
to evaluate the agreement between the two independent evaluators regarding PGT
treatment adherence to IEPPS-G. Results were considered significant at the α=0.05
level (two-
tailed). The Statistical Software for the Social Sciences (SPSS v.14) was used to
performed data analysis.
RESULTS
Of the fifty-eight patients included in the study, twenty-nine were randomly
assigned to PGT+CNZ and 29 to CNZ. None of the patients in the PGT+CNZ group
withdrew from the study, while five patients in the CNZ group withdrew from the
study due to dissatisfaction with random allocation (n=1), somnolence (n=3) and lack
of efficacy (n=1), resulting in 23 completer patients in CNZ group. There were no
differences regarding baseline characteristics between patients who completed the
study (data not shown).
96
When restricting the sample to completers, the only difference between the
treatment groups was that individuals randomized to the CNZ group had rates of
major depressive disorder (MDD) according to the M.I.N.I. (Amorim, 2000) that
were almost significantly higher than those of individuals randomized to the PGT
group (47.8% vs. 21.4%; p=0.073). Therefore MDD was evaluated as potential
confounder in the multivariable models evaluating psychodynamic efficacy
evaluation.
Both independent raters agreed (Kappa=1.0), that the therapist adhered to the
manual within its three distinct phases. Additionally they rated IEPPS-G >17 (mean
25.6; SD=2.7; min=18 max=29;); showing a good adherence to psychoanalytical
technique across the sessions
Defensive CNZ CNZ+PGT CNZ CNZ+PGT CNZ CNZ+PGT Time and treatment Co variables
style
(n=23) (n=28) (n=23) (n=28) (n=23) (n=28) Time Treatment Interaction Baseline Delta Delta MDD
DSQ DSQ LSAS
Mature 4.48±0.00 4.48±0.00 5.07±0.87 5.35±0.87 4.98±1.18 5.11±1.18 <.001 .443 .609 <.001 NI 0.074 NI
(0.306) (0.013) (0.010) (0.282) (0.056)
Neurotic 4.66±0.00 4.66±0.00 4.89±0.88 4.44±0.88 5.10±1.06 4.42±1.06 .001 .027 .045 0.027 0.539 NI NI
(0.132) (0.1) (0.064) (0.074) (0.013)
Immature 4.15±0.00 4.15±0.00 4.40±0.58 4.01±0.58 4.30±0.79 3.97±0.79 <.001 .038 .109 <.001 0.596 0.013 NI
(0.163) (0.091) (0.047) (0.196) (0.011) (0.090)
Abbreviations: CNZ = Clonazepam., PGT = Psychodynamic Group Therapy, DSQ-M, Defense Style Questionnaire – Mature Style, DSQ-N, Defense Style Questionnaire – Neurotic Style;
DSQ- I, Defense Style Questionnaire – Immature Style, ηp2 = Partial eta squared (effect size measure of ANCOVA), NI = Not Included for the multivariable model according to entry criteria
of p- value<.20. Statistics: Stepwise Analysis of Covariance (ANCOVA). Baseline scores of each defense scale respectively, SAD symptoms measured by Liebowitz Social Anxiety Scale
(LSAS) at baseline, changes in SAD symptoms across the 12-weeks measured by Delta LSAS (Week 12 LSAS minus Baseline LSAS) and Major Depression Disorder (MDD) rates were
evaluated in univariate Analysis of Variance (ANOVA) in predicting changes over the time in each Defense Style score. Each variable that achieved entry criteria (p-value<.20) was retained
in the multivariable model. Values in boldface represent significant results.
97
98
Discussion
To our knowledge, this is the first clinical trial to study changes in defense
styles between two short-term treatment modalities for SAD: a pharmacological and a
combined therapy (including a pharmacological and a psychodynamic intervention).
With this study design, we were able to separate the response due to symptoms
severity change, provided by a pharmacological agent, from the possible additional
benefits of brief psychodynamic group sessions. In the present study the three
defense styles changed along the 12 weeks of treatment, but the reasons for that
change differed among them as discussed bellow.
The present study found some differences between groups in the neurotic
defense style. Our study suggests that the addition of PGT to clonazepam promotes
a slight decrease in use of neurotic defenses in the short-term treatment of GSAD not
found in the CNZ group; in fact group there was a modest increase of the neurotic
style scores in the CNZ over time. PGT+CNZ helped patients decrease the use of
neurotic defenses even after controlling for possible confounding factors. This is
consistent with the goal of PGT when added to CNZ, i.e., to help individuals by
ameliorating underlying variables derived from the psychodynamic theoretical
model, e.g., defense mechanisms and defense styles for which there are now
validated measures (DSQ). Increase in the use of neurotic defense style in the CNZ
group may be due to a statistic phenomenon of test-retest, but specific effects of
CNZ cannot be ruled out. However, the short-term therapeutic intervention only
accounted for 6.4% of the variance of neurotic defense style change. It is possible
that longer-term therapies would produce larger effect sizes. Decrease in the use of
neurotic defense styles was not associated with symptoms improvement. This is
consistent with the idea that neurotic defenses are part of a relatively stable aspect of
personality (Andrews et al., 1989; Bond, 1992; Vaillant, 1971) and also that PGT, in
the short-term, was able to address defenses and conflicts (by means of each
individual focus interpretation), beyond symptomatic change. In a longer period of
time, it would possibly represent greater capacity of dealing with stressful situations,
consequently helping in relapse prevention. Two important questions for future
research are whether those gains are maintained over time and whether longer
treatments can
lead to even larger improvements.
Mature defense style increased in both groups. It is possible that mature
defense styles increased in both groups because patients were seen by a psychiatrist
and were motivated towards changes with treatment (nonspecific factors), which did
not differ between groups. These changes were also independent of symptoms
improvement. Additionally, it is important to note that the mature factor is the
weakest construct according to the validation study of DSQ-40 Brazilian-Portuguese
Version and therefore this limitation of the DSQ should be taken into account as a
possible explanation for this change (Blaya et al., 2006).
99
Immature defense style also changed in both groups, and similar to neurotic
style changes, the scores of both groups followed different directions: there was a
slight decrease in the PGT+CNZ group, whereas a modest increase in the CNZ group,
although with no significant difference between groups. It is possible that decrease in
the immature scores in the PGT+CNZ group might be due to the addition of PGT to
clonazepam as well, although we are aware of the fact that in this kind of therapy we
can offer just a first and fragmentary approach to the understanding of the underlying
conflicts in a neurotic level. Lack of significance might be due to lack of statistical
power and to a relatively short treatment period.
Immature defense style was the only defense style in the study found to be
influenced by symptomatic changes (LSAS), a finding in agreement with other
studies in depression (Akkerman et al., 1999), obsessive-compulsive disorder treated
with behavioral treatment (Albucher et al., 1998); panic disorder with treated
medication (Kipper et al., 2005) and panic disorder treated with cognitive-behavior
group therapy (Heldt et al., 2007). These findings stress the need of controlling for
baseline severity as done in the multivariate analyses. Also, baseline defense styles
were predictors of change in all the scales, and this might reflect regression toward
the mean that also need to be controlled.
One limitation of our study is its relatively short-term nature of PGT, a
limitation common to most studies on psychotherapy, even though many of those
studies target problems that tend to be chronic and recurrent (Bond; Perry, 2004). A
second limitation is that the relatively small sample size of the study, which reduced
its power to detect small differences. Finally, the sample was composed of treatment-
seeking patients with no severe depressive symptoms, creating a floor effect for the
detection of potential differences in improvement of depressive symptoms.
In conclusion, this study provides important empirical information on a novel
approach (PGT) with possible benefits regarding the global functioning of
individuals with GSAD (Knijnik et al., 2008; in press), using a psychoanalytical
approach and the additional benefits of PGT compared to CNZ in readjustment of the
neurotic defense style in the short term. Further studies should investigate the long-
term effects on defense styles of CNZ and PGT+CNZ, especially to evaluate larger
effect sizes.
REFERENCES
Akkerman K, Lewin TJ, Carr VJ (1999) Long-term changes in defense style among patients
recovering from major depression. Journal of Nervous and Ment Disease 187:80-87.
Albucher RC, Abelson JL, Nesse RM (1998) Defense mechanism changes in successfully
treated patients with obsessive-compulsive disorder. American Journal of Psychiatry
155:558- 559.
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American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders
(4th ed). Washington (DC): American Psychiatric Association.
Andrews G, Singh M, Bond M (1993) The defense style questionnaire. Journal of Nervous
and Ment Disease 181(4):246-256.
Blaya C, Kipper L, Heldt E, Isolan L, Ceitlin LH, Bond M, Manfro GG (2004) Brazilian
Portuguese version of the Defensive Style Questionnaire (DSQ-40) for defenses mechanisms
measure: A preliminary study. Revista Brasileira de Psiquiatria 26:255-258.
Bond M (1992) An empirical study of defensive styles: the defensive style questionnaire. In
GE Vaillant (Ed), Ego Mechanisms of Defense: A Guide for Clinicians and Researchers (pp
127-158). Washington DC: American Psychiatric Press.
Brom D, Kleber RJ, Defares PB (1989) Brief psychotherapy for posttraumatic stress disorders.
J Consult Clin Psychol 57:607-612.
Freud S (1953) The interpretation of dreams. In: Strachey J (ed), The Standart Edition of the
complete psychological works of Sigmund Freud (pp1-627). London: Hogarth Press.
Garner DM, Rockert W, Davis R, Garner MV, Olmsted MP, EagleM (1993) Comparison of
cognitive-behavioral and supportive-expressive therapy for bulimia nervosa. American
Journal of Psychiatry 150:37-46.
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Guy W (1976) Clinical global impressions (CGI). In ECDEU Assessment Manual for
Psychopharmacology (revised ed, pp 217-222). Rockville (MD): US National Institute of
Health, Psychopharmacology Research Branch.
Heldt E, et al (2007) Defense Mechanisms After Brief Cognitive-Behavior Group Therapy for
Panic Disorder One-Year Follow-Up. Journal of Nervous and Mental Disease 195:540-543.
Milrod B, Leon AC, Busch F (2007) A randomized controlled clinical trial of psychoanalytic
psychotherapy for panic disorder. American Journal of Psychiatry 164:265-272.
Roth A, Fonagy P (1999) What Works for Whom? A Critical Review of Psychotherapy
Research
(pp 197–215). New York, Guilford.
Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S, Startup M (1994) Effects of
treatment duration and severity of depression on the effectiveness of cognitive behavioral
and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 62:522-534.
8
DIVULGAÇÃO
PARCIAL DOS
RESULTADOS
EVENTOS
Pôsteres
• A Pilot Study of Clonazepam versus Psychodynamic Group Therapy plus
Clonazepam in the Treatment of Generalized Social Anxiety Disorder.
American Psychiatry Association – 158th Annual Meeting – San Diego, May
2007.
• Um estudo piloto de clonazepam versus Terapia Psicodinâmica em Grupo
mais clonazepam no tratamento da Fobia Social Generalizada. Congresso
Brasileiro de Psiquiatria – Porto Alegre, Outubro, 2007.
• Psychodynamic Group Therapy for Social Anxiety Disorder: A Treatment
Manual. Congresso Brasileiro de Psiquiatria – Porto Alegre, Outubro, 2007.
• Clonazepam versus Clonazepam e Terapia Psicodinâmica em Grupo no
Tra- tamento da Fobia Social Generalizada: Resultados Preliminares de 1
Ano de Seguimento. Congresso Brasileiro de Psiquiatria – Porto Alegre,
Outubro,
2007.
• Clonazepam (CNZ) versus Clonazepam e Terapia Psicodinâmica em
Grupo (CNZ+TPG) no Tratamento da Fobia Social Generalizada (FSG):
Desfecho
Psicodinâmico. Congresso Brasileiro de Psiquiatria – Porto Alegre, Outubro,
2007.
• Associações entre Estilo Defensivo e Fobia Social. Congresso Brasileiro de
Psiquiatria – Curitiba, Outubro 2006.
• Associações entre Estilo Defensivo e Fobia Social – Resultados Preliminares.
104
Semana Científica do Hospital de Clínicas de Porto Alegre – Porto Alegre,
2005.
105
Temas Livres
• Associações entre Estilo Defensivo e Fobia Social. Semana Científica do
Hospital de Clínicas de Porto Alegre, Porto Alegre, 2005.
• Associações entre Estilo Defensivo e Fobia Social. XXIII Jornada Sul-rio-
grandense de Psiquiatria Dinâmica, 2006.
Grand Rounds
• A Pilot Study of Clonazepam versus Psychodynamic Group Treatment plus
Clonazepam in the Treatment of Generalized Social Anxiety Disorder.
Coordination: Michael Liebowitz and Frank Schneier. Columbia
University
– NY, Maio 2006.
PUBLICAÇÕES EM ANAIS
• A Pilot Study of Clonazepam versus Psychodynamic Group Treatment plus
Clonazepam in the Treatment of Generalized Social Anxiety Disorder.
American Psychiatry Association – 158th Annual Meeting. New Research
Abstracts, p. 2-3, maio de 2007, San Diego, CA – USA.
106
9
CONSIDERAÇÕES FINAIS
A fobia social, em seu subtipo generalizado (FSG), foi por anos negligenciada,
mas hoje tem sido reconhecida como um dos transtornos psiquiátricos mais crônicos
e pre- valentes o qual reduz o real potencial de seus portadores em situações sociais.
No entanto, sabe-se que muitos psiquiatras não levam este diagnóstico tão a sério
como deveriam.
Na última década, muito progresso foi feito no que se refere ao tratamento da
FSG. Embora hoje exista uma série de terapias efetivas e se saiba que este transtorno
responde muito bem a tratamentos medicamentosos e psicoterápicos, cabe lembrar que
nem todos os pacientes apresentam melhora sintomática com as modalidades terapêuticas
já estabelecidas. Nesse sentido, julgamos ser importante examinar, com rigor
científico, o que a terapia de orientação psicodinâmica pode oferecer a um
transtorno cuja etiologia é multifatorial, especialmente em um setting de grupo.
Sabemos que a prática da terapia psicodinâmica hoje difere da psicanálise tradicional
de alguma forma, reflexo de tenta- tivas de aumentar a sua aplicabilidade e
efetividade em um maior número de pacientes. Em suma, esta tese aborda alguns
aspectos relacionados aos resultados de um ensaio clínico randomizado quanto à
resposta à adição de uma terapia psicodinâmica em grupo à medicação no que se
refere à melhora do funcionamento global, dos sintomas clínicos e da qualidade de
vida de portadores de FSG, bem como possíveis reajustamentos nos mecanismos de
defesa passíveis de serem alterados em 12 semanas através de uma
intervenção que visa a relacionar o binômio foco-sintoma.
Estes achados estimulam nossa pesquisa em psicoterapia e reforçam a
relevância de abordagens psicoterápicas dinâmicas para esta e para outras condições
nosológicas. Desta forma, ao descrever uma abordagem psicodinâmica em grupo
para a FSG, dentre os diferentes métodos de tratamento já estudados, sugerimos que
psiquiatras e psicote- rapeutas podem contar com um novo recurso na escolha do
tratamento de seus pacien- tes; também é de se destacar a tentativa de oferecer um
manual de tratamento que possa ser replicado em outros estudos.
107
ANEXO A
CGI – Gravidade
1. ☐ Muitíssimo melhor
2. ☐ Muito melhor
3. ☐ Um pouco melhor
4. ☐ Sem alteração
5. ☐ Um pouco pior
6. ☐ Muito pior
7. ☐ Muitíssimo pior
108
ANEXO B
MEDO/ EVITAÇÃO
ANSIEDADE
0 =Nenhum 0 =Nunca
1=Leve 1=Ocasionalmente
2=Moderado 2=Frequentemente
3=Intenso 3=Geralmente
1. Telefonar em público.
7. Ir a uma festa.
MEDO/ EVITAÇÃO
ANSIEDADE
0 =Nenhum 0 =Nunca
1=Leve 1=Ocasionalmente
2=Moderado 2=Frequentemente
3=Intenso 3=Geralmente
ANEXO C
ANEXO D
1. Eu fico satisfeito em ajudar os outros e, se eu não puder fazer isto, eu fico deprimido
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
2. Eu consigo não me preocupar com um problema até que eu tenha tempo para lidar com ele
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
3. Eu alivio a minha ansiedade fazendo coisas construtivas e criativas, como pintura e marcenaria
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
7. Se alguém me assalta e rouba o meu dinheiro, eu prefiro que esta pessoa seja ajudada em vez de punida
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
8. As pessoas dizem que eu costumo ignorar os fatos desagradáveis como se eles não existissem
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
10. Eu me orgulho da minha capacidade de reduzir as pessoas aos seus devidos lugares
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
114
12. Eu fico fisicamente doente quando as coisas não estão indo bem para mim
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
14. Eu fico mais satisfeito com minhas fantasias do que com a vida real
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
15. Eu tenho qualidades especiais que me permitem levar a vida sem problemas
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
16. Há sempre boas razões quando as coisas não dão certo pra mim
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
17. Eu resolvo mais as coisas sonhando acordado do que com a vida real
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
19. Às vezes, eu acho que sou um anjo e, outras vezes, acho que sou o demônio
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
21. Eu sempre acho que alguém que eu conheço é como um anjo da guarda
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
23. Se o meu chefe me repreendesse, eu poderia cometer um erro ou trabalhar mais devagar só para me
vingar dele
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
24. Eu conheço alguém que é capaz de ser justo e imparcial em qualquer coisa que faça
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
25. Eu posso controlar os meus sentimentos se eles interferirem no que eu estiver fazendo
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
26. Eu frequentemente sou capaz de ver o lado engraçado de uma situação apesar de ela ser desagradável
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
27. Eu sinto dor de cabeça quando tenho que fazer algo que não gosto
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
115
28. Eu frequentemente me vejo sendo muito simpático com pessoas com quem, pelo certo, eu deveria
estar muito irritado
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
30. Quando eu sei que vou ter que enfrentar uma situação difícil, eu tento imaginar como isso será e planejo
um jeito de lidar com a situação
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
32. Depois de lutar pelos meus direitos, eu tenho a tendência de me desculpar por ter sido tão firme
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
33. Quando eu estou deprimido ou ansioso, comer faz com que eu me sinta melhor
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
35. Se eu puder saber com antecedência que vou ficar triste mais adiante, eu poderei lidar melhor com a
situação
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
36. Não importa o quanto eu reclame, eu nunca consigo uma resposta satisfatória
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
37. Frequentemente eu me dou conta de que eu não sinto nada em situações que deveriam me despertar
fortes emoções
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
39. Se eu estivesse passando por uma crise, eu me aproximaria de pessoas que tivessem o mesmo problema
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
40. Se eu tenho um pensamento agressivo,eu sinto a necessidade de fazer algo para compensá-lo
Discordo completamente 1 2 3 4 5 6 7 8 9 Concordo plenamente
116
ANEXO E
Por favor, tenha em mente seus valores, aspirações, prazeres e preocupações. Nós
estamos perguntando o que você acha de sua vida, tomando como referência as duas
últimas semanas.
Por favor, leia cada questão, veja o que você acha e circule o número que lhe parecer
a melhor resposta.
As questões seguintes são sobre o quanto você tem sentido algumas coisas nas últimas duas semanas.
As questões seguintes perguntam sobre quão completamente você tem sentido ou é capaz de fazer
certas coisas nessas últimas duas semanas.
As questões seguintes perguntam sobre quão bem ou satisfeito você se sentiu a respeito de vários
aspectos de sua vida nas últimas duas semanas.
As questões seguintes referem-se a com que freqüência você sentiu ou experimentou certas coisas nas
últimas duas semanas.
ANEXO F
Instrução: Assinale SIM ou NÃO nos itens abaixo de acordo com as intervenções rea-
lizadas pelo terapeuta durante a sessão.
PONTUAÇÃO A) B) C) D) E) F) Total=
Obs: F= F1 + F2
124
ANEXO G
Dear Editors,
Since S. Freud postulated, through the analysis of patients, the technical and
methapsychicological aspects that lead to the consolidation of phsychoanalysis as a
science, more than a hundred years of clinical experience corroborate it as a useful
instrument to treat psychic pain, symptoms and interpersonal problems. However, the
advent of evidence based medicine brought the challange of developing adequate
tools and methods to investigate systematically the effectiveness of the analytical
model and specific aspects related to patient‘s changing process. The efficacy of
manualized analytical oriented treatments of several psychiatric pathologies is well
established through clinical trials (Fonagy, Roth and Higgitt, 2005; Roth and Fonagy,
2005; Leichsenring and Leibing, 2007; Mildrod, Leon and Busch, 2007). However,
studies in analytically oriented group psychotherapy are still incipient (Knijnik et al.,
2004; Knijnik et al. [In press]).
To ensure the use of proper methodology in studies aiming to investigate
psychotherapy methods, one must carefully define the technique that is being tested
and how to measure if the treatment corresponds to the defined model, for example, a
psychoanalytical approach. In 1985, E. Jones developed an instrument with the
purpose of investigating the role of different factors involved in therapeutic process,
the Psychotherapy Process Q-Sort (PQS), which was published a couple of years later
(Jones, 2000). The PQS comprises 100 items describing a wide range of treatment
aspects.
Financing: The project was financed by the Fundo de Incentivo à Pesquisa e Ensino
do Hospital de Clínicas Porto Alegre (FIPE-HCPA), and was approved in respect of
its ethical and methodological aspects by GPPG-HCPA.
REFERENCES
1. Fonagy P, Roth, A, Higgitt A (2005). Psychodynamic psychotherapies: evidence-based
practice and clinical wisdom. Bulletin of the Menninger Clinic, 69(1):1-58.
3. Jones, E.E. (1985). Manual for the Psychotherapy Process Q-sort. Unpublished
manuscript, University of California, Berkeley.
6. Knijnik, DZ, Blanco, CJ, Moraes,C, Salum GA, Eizirik, CL Psychodynamic Group
Therapy for Social Anxiety Disorder: A Treatment Manual. International Journal of Group
Psychotherapy. European Psychiatry, In Press.
10. Roth A, Fonagy, P (2005). What works for whom? A critical review of psychotherapy
research. Second Edition. New York: Guilford.
127
APÊNDICE 1
Itens importantes
Você tem a liberdade de desistir do estudo a qualquer momento, sem fornecer
um motivo, assim como pedir maiores informações sobre o mesmo e o procedimento
a ser feito.
Declaração:
Eu, declaro que:
Nome do paciente:
Assinatura do paciente:
Data:
APÊNDICE 2
PROTOCOLO DE PESQUISA
A. Dados demográficos:
1. Nome:
2. Sexo: (0) feminino (1) masculino
3. Data de nascimento: Idade:
4. Prontuário:
5. Endereço: CEP: Cidade:
6. Telefones:
7. Maior grau de instrução: Anos completos de estudo: anos
(Ensino fundamental = 1; Ensino fundamental incompleto = 2; Ensino médio completo = 3;
Ensino médio incompleto = 4; Ensino superior incompleto = 5; Ensino superior completo = 6;
Pós- graduação = 7)
B. Perfil socioeconômico:
1. Situação conjugal:
(Casado = 1; Solteiro = 2; Viúvo = 3; Divorciado = 4; Separado = 5)
3. Ocupação:
(Emprego em tempo integral = 1; Emprego em meio-turno = 2; Dona de casa = 3; Aposentado =
4; Serviço militar = 5; Desempregado = 6; Estudante = 7; Outro = 8)
Rádio 0 1 2 3 4 5 6
Banheiro 0 2 4 6 8 10 12
Carro 0 4 8 12 16 16 16
Empregada 0 6 12 18 24 24 24
Telefone 0 5 5 5 5 5 5
Geladeira 0 2 2 2 2 2 2
C. Dados gerais:
1. Idade de início dos sintomas de fobia social: anos
2. Tempo de duração da fobia social: anos
3. Tempo entre o diagnóstico de fobia social e procura por tratamento: anos
4. Presença de trauma que relacione com a fobia social:
5. História familiar para doença psiquiátrica:
(Transtorno do pânico = 1; Transtorno de ansiedade = 2; Transtorno do humor (bipolar,
depressão, etc.) = 3; Dependência química = 4; Outra = 5; Não sabe = 6; Não tem = 7)
132
6. Grau de parentesco:
(Mãe = 1; Pai = 2; Irmãs = 3; Irmãos = 4; Avós maternos = 5; Avós paternos = 6; Tios maternos
= 7; Tios paternos = 8; Primos maternos = 9; Primos paternos = 10; Filhas = 11; Filhos = 12;
Não sabe = 13; Não tem = 14)
D. Variáveis do estudo
1. Instrumentos de avaliação
CGI-S
CGI-I
LSAS Total
WHOQOL-Bref
DSQ-40
BDI